MEDICARE: DR. KINIYA CHANTERA CHURCH DNP, FNP-C, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024171501	VA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024171501	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C04555	OTHER	VA	GROUP PTAN
2	C05149	OTHER	VA	GROUP PTAN
3	C05403	OTHER	VA	GROUP PTAN
4	GC1103	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1215352554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KINIYA CHANTERA CHURCH DNP, FNP-C, PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 748465
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8465
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:	617-807-0958

Provider Business Practice Location Address
First Line	:	3804 POPLAR HILL RD STE D
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-5532
Country	:	US
Telephone Number	:	757-210-9381
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2014
Last Update Date	:	10/17/2025

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