Provider Demographics
NPI:1629435243
Name:GILLEN, CHASTITY (2014044014)
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:
Last Name:GILLEN
Suffix:
Gender:F
Credentials:2014044014
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155550S 2519 RD
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MO
Mailing Address - Zip Code:64790
Mailing Address - Country:US
Mailing Address - Phone:417-684-5784
Mailing Address - Fax:
Practice Address - Street 1:805 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-9382
Practice Address - Country:US
Practice Address - Phone:660-679-4636
Practice Address - Fax:660-679-4310
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014044014163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse