Provider Demographics
NPI:1285152462
Name:WALKER, CHANTALLE J (PA-C)
Entity type:Individual
Prefix:
First Name:CHANTALLE
Middle Name:J
Last Name:WALKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHANTALLE
Other - Middle Name:J
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7051 HEATHCOTE VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3196
Mailing Address - Country:US
Mailing Address - Phone:571-248-0167
Mailing Address - Fax:571-248-0173
Practice Address - Street 1:7051 HEATHCOTE VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3196
Practice Address - Country:US
Practice Address - Phone:571-248-0167
Practice Address - Fax:571-248-0173
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031383363A00000X
NY022133363A00000X
VA0110005852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110005852OtherPA LICENSE
NY022133OtherPA LICENSE
DCPA031383OtherPA LICENSE