Provider Demographics
NPI:1124629761
Name:RAINES, CHANTELLE A (RD,LDN)
Entity type:Individual
Prefix:MRS
First Name:CHANTELLE
Middle Name:A
Last Name:RAINES
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 CONOR CT
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-6270
Mailing Address - Country:US
Mailing Address - Phone:904-469-4512
Mailing Address - Fax:
Practice Address - Street 1:4560 CRAIN HWY STE 1
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3084
Practice Address - Country:US
Practice Address - Phone:240-210-9725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA86116533133V00000X
MDDX5121133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty