Provider Demographics
NPI:1851961601
Name:CHANEY, TAKITA
Entity Type:Individual
Prefix:
First Name:TAKITA
Middle Name:
Last Name:CHANEY
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 1:736 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-3003
Mailing Address - Country:US
Mailing Address - Phone:601-407-8591
Mailing Address - Fax:
Practice Address - Street 1:736 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-3003
Practice Address - Country:US
Practice Address - Phone:601-407-8591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide