Provider Demographics
NPI:1659024446
Name:KILGOE, CHAUNTA
Entity Type:Individual
Prefix:
First Name:CHAUNTA
Middle Name:
Last Name:KILGOE
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 1:590 NAAMANS RD
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 N HIGH STREET EXTENDED
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1183
Practice Address - Country:US
Practice Address - Phone:833-886-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL2-0012014164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEL2-0012014Medicaid