Provider Demographics
NPI:1114462850
Name:EASTMAN, CHANELLE
Entity Type:Individual
Prefix:MISS
First Name:CHANELLE
Middle Name:
Last Name:EASTMAN
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 1:924 LACKAWANNA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1525
Mailing Address - Country:US
Mailing Address - Phone:607-333-4033
Mailing Address - Fax:
Practice Address - Street 1:924 LACKAWANNA AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1525
Practice Address - Country:US
Practice Address - Phone:607-333-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse