Provider Demographics
NPI:1053033464
Name:MARTIN, CHAUNTA DENISE
Entity type:Individual
Prefix:MS
First Name:CHAUNTA
Middle Name:DENISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 OGLETHORPE DR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-3676
Mailing Address - Country:US
Mailing Address - Phone:912-940-2019
Mailing Address - Fax:
Practice Address - Street 1:1407 OGLETHORPE DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-3676
Practice Address - Country:US
Practice Address - Phone:912-940-2019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0554212259343900000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)