Provider Demographics
NPI:1730833047
Name:VIXAMAR, CHANTALE
Entity type:Individual
Prefix:
First Name:CHANTALE
Middle Name:
Last Name:VIXAMAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10184 SOUTHERN PRIDE PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8007
Mailing Address - Country:US
Mailing Address - Phone:561-904-1363
Mailing Address - Fax:
Practice Address - Street 1:10184 SOUTHERN PRIDE PL
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8007
Practice Address - Country:US
Practice Address - Phone:561-904-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily