MEDICARE: CHANTALLE HURTGAM LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	297340	NY

General Provider Information

NPI Number	:	1952539298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANTALLE HURTGAM LPN

Provider Business Mailing Address
First Line	:	2753 ANGLING RD
Second Line	:
City	:	MEDINA
State	:	NY
Zip	:	14103-9651
Country	:	US
Telephone Number	:	585-615-1957
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 WEHRLE DR
Second Line	:	SUITE 1
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-7034
Country	:	US
Telephone Number	:	716-276-2123
Fax Number	:	716-276-2129

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2009
Last Update Date	:	06/25/2009

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