Provider Demographics
NPI:1902990328
Name:CHESTNUT, KELLIE DERAE (ITDS, MAE)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:DERAE
Last Name:CHESTNUT
Suffix:
Gender:F
Credentials:ITDS, MAE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6810
Mailing Address - Country:US
Mailing Address - Phone:270-847-5723
Mailing Address - Fax:
Practice Address - Street 1:910 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6810
Practice Address - Country:US
Practice Address - Phone:270-847-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator