Provider Demographics
NPI:1922253442
Name:JOHNSON, CHANTEL KAFAYAT
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:KAFAYAT
Last Name:JOHNSON
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 1:240 N. FREDERICK AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-255-5569
Mailing Address - Fax:386-255-5277
Practice Address - Street 1:240 N. FREDERICK AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-255-5569
Practice Address - Fax:386-255-5277
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000218500Medicaid