Provider Demographics
NPI:1902375124
Name:KISTLER, CHELSEY PAINTER
Entity Type:Individual
Prefix:
First Name:CHELSEY
Middle Name:PAINTER
Last Name:KISTLER
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 1:5013 LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4016 RAINTREE RD # 100A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316051287Medicaid