Provider Demographics
NPI:1649802711
Name:DESHIELDS, CHANTELL (NP)
Entity type:Individual
Prefix:
First Name:CHANTELL
Middle Name:
Last Name:DESHIELDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 E PHIL ELLENA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1943
Mailing Address - Country:US
Mailing Address - Phone:267-974-3971
Mailing Address - Fax:
Practice Address - Street 1:2 PENN BLVD STE 103
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-1402
Practice Address - Country:US
Practice Address - Phone:215-842-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020342363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics