Healthcare Provider Details

I. General information

NPI: 1467574137
Provider Name (Legal Business Name): CHANTON LAM-COPELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 N PERSHING AVE STE D2
STOCKTON CA
95207-6967
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-8843
  • Fax: 209-953-8476
Mailing address:
  • Phone: 209-953-7524
  • Fax: 209-953-7526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: