Provider Demographics
NPI:1023334430
Name:KELLY, CHANTAL NICOLE (MS, CGC)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:NICOLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 TW ALEXANDER DRIVE
Mailing Address - Street 2:CENTER FOR MOLECULAR BIOLOGY AND PATHOLOGY
Mailing Address - City:RESEARCH TRIANGLE PARK
Mailing Address - State:NC
Mailing Address - Zip Code:27709-0005
Mailing Address - Country:US
Mailing Address - Phone:800-533-0567
Mailing Address - Fax:919-361-7798
Practice Address - Street 1:1912 TW ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:RESEARCH TRIANGLE PARK
Practice Address - State:NC
Practice Address - Zip Code:27709-0007
Practice Address - Country:US
Practice Address - Phone:800-533-0567
Practice Address - Fax:919-361-7798
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
12471OtherAMERICAN BOARD OF GENETIC COUNSELING