Healthcare Provider Details

I. General information

NPI: 1952942708
Provider Name (Legal Business Name): SHANTE CHAMBLISS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SEVERANCE CIR
CLEVELAND HEIGHTS OH
44118-1566
US

IV. Provider business mailing address

5 SEVERANCE CIR
CLEVELAND HEIGHTS OH
44118-1566
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-5571
  • Fax:
Mailing address:
  • Phone: 216-291-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024053
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: