Provider Demographics
NPI:1235369380
Name:ANDERSON, CHANTEL KELLY (NP)
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:KELLY
Last Name:ANDERSON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2147
Mailing Address - Country:US
Mailing Address - Phone:765-250-9212
Mailing Address - Fax:765-588-0327
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2147
Practice Address - Country:US
Practice Address - Phone:765-250-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002987A363L00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002987AOtherNP LICENSE