Provider Demographics
NPI:1639509201
Name:CHASTAIN, MISTY NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:NICOLE
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 LYNNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-4491
Mailing Address - Country:US
Mailing Address - Phone:765-425-1232
Mailing Address - Fax:
Practice Address - Street 1:1100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3462
Practice Address - Country:US
Practice Address - Phone:765-641-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001344A174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator