Provider Demographics
NPI:1679266761
Name:DONALD, CHARDONEE (CHN, CNS)
Entity type:Individual
Prefix:
First Name:CHARDONEE
Middle Name:
Last Name:DONALD
Suffix:
Gender:F
Credentials:CHN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 CAPRON CT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4346
Mailing Address - Country:US
Mailing Address - Phone:630-518-0909
Mailing Address - Fax:
Practice Address - Street 1:12400 MIDSUMMER LN APT C201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6704
Practice Address - Country:US
Practice Address - Phone:630-518-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6044133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist