Provider Demographics
NPI:1144978610
Name:MARDNER, CHANTAY T (SPECIALIST)
Entity type:Individual
Prefix:MS
First Name:CHANTAY
Middle Name:T
Last Name:MARDNER
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ARBOR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-0288
Mailing Address - Country:US
Mailing Address - Phone:404-717-2714
Mailing Address - Fax:
Practice Address - Street 1:4531 OLDE PERIMETER WAY STE 101
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30346-4208
Practice Address - Country:US
Practice Address - Phone:404-717-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1195861744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management