Provider Demographics
NPI:1659955375
Name:ROSHELL, CHANTIRA MONIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:CHANTIRA
Middle Name:MONIQUE
Last Name:ROSHELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N86W14322 FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3266
Mailing Address - Country:US
Mailing Address - Phone:414-484-9465
Mailing Address - Fax:
Practice Address - Street 1:N86W14322 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3266
Practice Address - Country:US
Practice Address - Phone:414-484-9465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-09
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI326242-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse