Provider Demographics
NPI:1619634912
Name:KIRK, CHANTEL L
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:L
Last Name:KIRK
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 1:241 COUNTY ROAD 819
Mailing Address - Street 2:
Mailing Address - City:BUNA
Mailing Address - State:TX
Mailing Address - Zip Code:77612-6119
Mailing Address - Country:US
Mailing Address - Phone:409-382-3702
Mailing Address - Fax:
Practice Address - Street 1:241 COUNTY ROAD 819
Practice Address - Street 2:
Practice Address - City:BUNA
Practice Address - State:TX
Practice Address - Zip Code:77612-6119
Practice Address - Country:US
Practice Address - Phone:409-382-3702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233262164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse