Healthcare Provider Details

I. General information

NPI: 1225550734
Provider Name (Legal Business Name): MRS. CHANTELLE ELIZABETH ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2618 S LYLE ST
KENNEWICK WA
99337-7821
US

IV. Provider business mailing address

2618 S LYLE ST
KENNEWICK WA
99337-7821
US

V. Phone/Fax

Practice location:
  • Phone: 505-860-1359
  • Fax:
Mailing address:
  • Phone: 505-860-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: