Provider Demographics
NPI:1407546864
Name:ECKLAND JOHNSON, CHANTEL BROOK
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:BROOK
Last Name:ECKLAND JOHNSON
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 1:1818 E DEERHILL DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8174
Mailing Address - Country:US
Mailing Address - Phone:907-957-6614
Mailing Address - Fax:
Practice Address - Street 1:1500 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:907-957-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program