Provider Demographics
NPI:1447515275
Name:BRUYN, CHANTELLE M (PT)
Entity type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:M
Last Name:BRUYN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHANTELLE
Other - Middle Name:MARIE
Other - Last Name:PALACIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73-5590 KAUHOLA ST STE A
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2610
Mailing Address - Country:US
Mailing Address - Phone:808-329-7744
Mailing Address - Fax:808-334-1608
Practice Address - Street 1:73-5590 KAUHOLA ST STE A
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2610
Practice Address - Country:US
Practice Address - Phone:808-329-7744
Practice Address - Fax:808-334-1608
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60292662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist