Provider Demographics
NPI:1467054254
Name:BAKER, CHANTELLE
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:
Last Name:BAKER
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 1:402 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:45346-9786
Mailing Address - Country:US
Mailing Address - Phone:937-417-4594
Mailing Address - Fax:
Practice Address - Street 1:402 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW MADISON
Practice Address - State:OH
Practice Address - Zip Code:45346-9786
Practice Address - Country:US
Practice Address - Phone:937-417-4594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0180976Medicaid