1831529130 NPI number — SHANTORA CHAMBERLISS

Table of content: SHANTORA CHAMBERLISS (NPI 1831529130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831529130 NPI number — SHANTORA CHAMBERLISS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERLISS
Provider First Name:
SHANTORA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831529130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/09/2021
NPI Reactivation Date:
03/19/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23666-1765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-788-0300
Provider Business Mailing Address Fax Number:
757-788-0969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MEDICAL DR
Provider Second Line Business Practice Location Address:
STE A/B
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-1769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-788-0600
Provider Business Practice Location Address Fax Number:
757-788-0932
Provider Enumeration Date:
11/22/2013

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: 1041C0700X , with the licence number:  0904008370 , 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: 1659424448 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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