Provider Demographics
NPI:1205569142
Name:BEAUREGARD, CHANTEL (CNC, CNS, FNLP)
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:CNC, CNS, FNLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 JOHNSON AVE STE 119
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3306
Mailing Address - Country:US
Mailing Address - Phone:323-676-1879
Mailing Address - Fax:
Practice Address - Street 1:101 ATLANTIC AVE STE 104
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-5175
Practice Address - Country:US
Practice Address - Phone:323-676-1879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist