Provider Demographics
NPI:1952882599
Name:KING, CHANTEL BRIANNA
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:BRIANNA
Last Name:KING
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 1:897 OAK ST
Mailing Address - Street 2:
Mailing Address - City:LENNON
Mailing Address - State:MI
Mailing Address - Zip Code:48449-9300
Mailing Address - Country:US
Mailing Address - Phone:248-210-6711
Mailing Address - Fax:
Practice Address - Street 1:110 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4600
Practice Address - Country:US
Practice Address - Phone:810-535-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid