Provider Demographics
NPI:1649883570
Name:ST MARTIN, CHANEL (PA)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:ST MARTIN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9792
Mailing Address - Country:US
Mailing Address - Phone:352-527-6888
Mailing Address - Fax:
Practice Address - Street 1:2385 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9677
Practice Address - Country:US
Practice Address - Phone:352-527-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPPA184363A00000X
PR000758-PA363A00000X
AZ8551363A00000X
FLPACN1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant