Provider Demographics
NPI:1720630411
Name:THEODORE, CHANTAL R
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:R
Last Name:THEODORE
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 1:1414 KUHL AVE # MP38
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:321-842-4713
Mailing Address - Fax:
Practice Address - Street 1:1222 S ORANGE AVENUE 4TH FL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32891-2027
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00883700363LF0000X
FLAPRN11016089363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily