Provider Demographics
NPI:1548953458
Name:PROFETA, CHESTER G (BSN, MSN)
Entity type:Individual
Prefix:
First Name:CHESTER
Middle Name:G
Last Name:PROFETA
Suffix:
Gender:M
Credentials:BSN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2571 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-2942
Mailing Address - Country:US
Mailing Address - Phone:714-588-6599
Mailing Address - Fax:
Practice Address - Street 1:1260 AJIJAAK AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8330
Practice Address - Country:US
Practice Address - Phone:714-588-6659
Practice Address - Fax:231-242-1700
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA846065163WP0808X
MI4704420286363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health