Provider Demographics
NPI:1932682424
Name:KING, CHANTAL J
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:J
Last Name:KING
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 1:1414 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 W CENTRAL AVE STE G
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2830
Practice Address - Country:US
Practice Address - Phone:805-735-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56242363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant