Provider Demographics
NPI:1124457197
Name:CHASTAIN, TAYLOR MARIE (BS, BA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:BS, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S PARK ST # 1
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5118
Mailing Address - Country:US
Mailing Address - Phone:269-317-8744
Mailing Address - Fax:
Practice Address - Street 1:504 S PARK ST # 1
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5118
Practice Address - Country:US
Practice Address - Phone:269-317-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-10
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor