Provider Demographics
NPI:1710359922
Name:CHATHAM, CHANTEL NICOLE (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:CHANTEL
Middle Name:NICOLE
Last Name:CHATHAM
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 COLLEGE DR # 5114
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39406-0001
Mailing Address - Country:US
Mailing Address - Phone:228-214-3319
Mailing Address - Fax:228-214-3272
Practice Address - Street 1:118 COLLEGE DR # 5114
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0001
Practice Address - Country:US
Practice Address - Phone:228-214-3319
Practice Address - Fax:228-214-3272
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1689133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered