Provider Demographics
NPI:1235762600
Name:CHANCELLOR, ALEXIS NICOLE (RD/LD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:CHANCELLOR
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0350
Mailing Address - Country:US
Mailing Address - Phone:918-253-1744
Mailing Address - Fax:
Practice Address - Street 1:859 E MELTON DR
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-2704
Practice Address - Country:US
Practice Address - Phone:918-253-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2490133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered