Provider Demographics
NPI:1154929883
Name:POIRIER, CHANTAL NICOLE
Entity type:Individual
Prefix:MS
First Name:CHANTAL
Middle Name:NICOLE
Last Name:POIRIER
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 1:1720 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0608
Mailing Address - Country:US
Mailing Address - Phone:408-371-7191
Mailing Address - Fax:
Practice Address - Street 1:1720 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0608
Practice Address - Country:US
Practice Address - Phone:408-371-7191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherPRIVATE