Provider Demographics
NPI:1164058335
Name:MCCLOGGAN, CHANIYA TRENISE
Entity Type:Individual
Prefix:
First Name:CHANIYA
Middle Name:TRENISE
Last Name:MCCLOGGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 STEAM MILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-4819
Mailing Address - Country:US
Mailing Address - Phone:762-821-3112
Mailing Address - Fax:
Practice Address - Street 1:4067 STEAM MILL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-4819
Practice Address - Country:US
Practice Address - Phone:762-821-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker