Provider Demographics
NPI:1467298273
Name:WILLSON, CHANTALL (CFM, CST, CNA)
Entity type:Individual
Prefix:
First Name:CHANTALL
Middle Name:
Last Name:WILLSON
Suffix:
Gender:F
Credentials:CFM, CST, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 W WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2002
Mailing Address - Country:US
Mailing Address - Phone:715-486-6343
Mailing Address - Fax:
Practice Address - Street 1:1607 W WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2002
Practice Address - Country:US
Practice Address - Phone:715-486-6343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI246ZS0410X
WICFM03571224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist