Provider Demographics
NPI:1083125553
Name:PERRY, CHANTALE (RN)
Entity Type:Individual
Prefix:
First Name:CHANTALE
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WAYSIDE INN RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1716
Mailing Address - Country:US
Mailing Address - Phone:508-405-5402
Mailing Address - Fax:
Practice Address - Street 1:98 PERRY AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2112
Practice Address - Country:US
Practice Address - Phone:508-405-5402
Practice Address - Fax:508-405-5402
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2308061163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000000000000000OtherNON MEDICAL