Provider Demographics
NPI:1124049838
Name:CHATELAIN, MANDA LOUISE (NP)
Entity type:Individual
Prefix:
First Name:MANDA
Middle Name:LOUISE
Last Name:CHATELAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:1331 N 7TH ST STE 405
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2754
Practice Address - Country:US
Practice Address - Phone:602-254-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1568207T00000X, 363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860224285OtherTAX ID
AZ188316200OtherDEPT OF LABOR ID
AZ1Z9797OtherHEALTHNET
AZCD4863OtherRAILROAD MEDICARE ID
AZ751679Medicaid
AZAZ0143190OtherBC BS ID