1285152462 NPI number — CHANTALLE J WALKER PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285152462 NPI number — CHANTALLE J WALKER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKER
Provider First Name:
CHANTALLE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
CHANTALLE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285152462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7051 HEATHCOTE VILLAGE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20155-3196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-248-0167
Provider Business Mailing Address Fax Number:
571-248-0173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7051 HEATHCOTE VILLAGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20155-3196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-248-0167
Provider Business Practice Location Address Fax Number:
571-248-0173
Provider Enumeration Date:
09/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA031383 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 022133 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110005852 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0110005852 . This is a "PA LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 022133 . This is a "PA LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PA031383 . This is a "PA LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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