Provider Demographics
NPI:1700588423
Name:MARTIN, CHANTELLE GRACE (MBCHB)
Entity Type:Individual
Prefix:DR
First Name:CHANTELLE
Middle Name:GRACE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:CHANTELLE
Other - Middle Name:GRACE
Other - Last Name:WILLMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:380 HOSPITAL DRIVE, BUILDING A
Mailing Address - Street 2:SUITE 430
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217
Mailing Address - Country:US
Mailing Address - Phone:478-751-0367
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-751-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program