Provider Demographics
NPI:1205349016
Name:HARRIS, CHAUNTACEY MONIQUE
Entity type:Individual
Prefix:
First Name:CHAUNTACEY
Middle Name:MONIQUE
Last Name:HARRIS
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 1:552 NICHOLAS ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-2918
Mailing Address - Country:US
Mailing Address - Phone:419-283-0085
Mailing Address - Fax:
Practice Address - Street 1:2005 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1703
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:419-841-1691
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159468164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid