Provider Demographics
NPI:1588113328
Name:CHALOUX, BRENDA LEE
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:CHALOUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LEE
Other - Last Name:JAEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:180 GENERAL KNOX RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:MA
Mailing Address - Zip Code:01071-9734
Mailing Address - Country:US
Mailing Address - Phone:413-348-6089
Mailing Address - Fax:
Practice Address - Street 1:73 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:MA
Practice Address - Zip Code:01050-9777
Practice Address - Country:US
Practice Address - Phone:413-667-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN198146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily