Healthcare Provider Details

I. General information

NPI: 1760310163
Provider Name (Legal Business Name): CHANCELER PEMBERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CALO LN
LAKE OZARK MO
65049-9208
US

IV. Provider business mailing address

130 CALO LN
LAKE OZARK MO
65049-9208
US

V. Phone/Fax

Practice location:
  • Phone: 573-745-5253
  • Fax:
Mailing address:
  • Phone: 573-745-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2023011514
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: