Provider Demographics
NPI:1679939961
Name:LIPPERT, CHANTELLE ROSE
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:ROSE
Last Name:LIPPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANTELLE
Other - Middle Name:ROSE
Other - Last Name:GRENINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:290 IOOF AVE
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5204
Mailing Address - Country:US
Mailing Address - Phone:831-524-6228
Mailing Address - Fax:
Practice Address - Street 1:290 IOOF AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5204
Practice Address - Country:US
Practice Address - Phone:831-524-6228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-03
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LVN-284207171M00000X
CALVN-284207164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator