Provider Demographics
NPI:1942814900
Name:AMERSON, CHANTIANA
Entity Type:Individual
Prefix:
First Name:CHANTIANA
Middle Name:
Last Name:AMERSON
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 1:2464 FENTON PKWY APT 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-6705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2464 FENTON PKWY APT 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-6705
Practice Address - Country:US
Practice Address - Phone:214-609-5146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83481225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist