Provider Demographics
NPI:1689134686
Name:CHAMBERLAIN, CARLY HANNAH
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:HANNAH
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1013
Mailing Address - Country:US
Mailing Address - Phone:302-320-4410
Mailing Address - Fax:302-428-4078
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-320-4410
Practice Address - Fax:302-428-4078
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0024178207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine