Provider Demographics
NPI:1053624775
Name:CHILDRESS, CHANTAL A (LPN)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:A
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20293 EMERY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RANDALL
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4122
Mailing Address - Country:US
Mailing Address - Phone:216-663-8441
Mailing Address - Fax:
Practice Address - Street 1:20293 EMERY RD
Practice Address - Street 2:
Practice Address - City:NORTH RANDALL
Practice Address - State:OH
Practice Address - Zip Code:44128-4122
Practice Address - Country:US
Practice Address - Phone:216-663-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-099322164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse