Provider Demographics
NPI:1215275318
Name:PHILISTIN, CHANTALE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:CHANTALE
Middle Name:
Last Name:PHILISTIN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:CHANTALE
Other - Middle Name:PAUL
Other - Last Name:LATORTUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2505 BOSWELL STREET
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9306
Mailing Address - Country:US
Mailing Address - Phone:929-220-6062
Mailing Address - Fax:718-676-9238
Practice Address - Street 1:2681 W 2ND ST
Practice Address - Street 2:APT 5C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6377
Practice Address - Country:US
Practice Address - Phone:929-220-6062
Practice Address - Fax:718-676-9238
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200023-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1215275318Medicaid