Healthcare Provider Details

I. General information

NPI: 1285152462
Provider Name (Legal Business Name): CHANTALLE J WALKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANTALLE J JACKSON PA-C

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7051 HEATHCOTE VILLAGE WAY
GAINESVILLE VA
20155-3196
US

IV. Provider business mailing address

7051 HEATHCOTE VILLAGE WAY
GAINESVILLE VA
20155-3196
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-0167
  • Fax: 571-248-0173
Mailing address:
  • Phone: 571-248-0167
  • Fax: 571-248-0173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031383
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022133
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005852
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: