Provider Demographics
NPI:1194496315
Name:COMSTOCK, CHANTELE (LPN)
Entity type:Individual
Prefix:
First Name:CHANTELE
Middle Name:
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CHANTELE
Other - Middle Name:
Other - Last Name:EASTLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1364
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-1364
Mailing Address - Country:US
Mailing Address - Phone:716-244-2223
Mailing Address - Fax:
Practice Address - Street 1:5934 SUGARTOWN RD
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731-9722
Practice Address - Country:US
Practice Address - Phone:716-244-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340569-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse