Provider Demographics
NPI:1124855168
Name:STOUFFIS, CHANTELLE TAREA (LPN)
Entity type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:TAREA
Last Name:STOUFFIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 CRYSTAL RIVER ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8815
Mailing Address - Country:US
Mailing Address - Phone:616-930-2661
Mailing Address - Fax:
Practice Address - Street 1:1256 WALKER AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4067
Practice Address - Country:US
Practice Address - Phone:616-451-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703123727164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse