Healthcare Provider Details

I. General information

NPI: 1639863285
Provider Name (Legal Business Name): CHANTELLE THANDEKA WHITE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 JOE DIMAGGIO DR
HOLLYWOOD FL
33021-5487
US

IV. Provider business mailing address

10366 E CLAIRMONT CIR
TAMARAC FL
33321-7835
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-5324
  • Fax:
Mailing address:
  • Phone: 954-347-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: