Healthcare Provider Details

I. General information

NPI: 1942440508
Provider Name (Legal Business Name): DWANENE JORETTA CHAMBLEE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 ARBOR VITAE DR
LANSING MI
48917-9630
US

IV. Provider business mailing address

706 ARBOR VITAE DR
LANSING MI
48917-9630
US

V. Phone/Fax

Practice location:
  • Phone: 517-449-6858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0650
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: