Provider Demographics
NPI:1235997412
Name:TREVINO, CHANEL NICHOLE
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:NICHOLE
Last Name:TREVINO
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 1:2189 CRANE HAWK LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3917
Mailing Address - Country:US
Mailing Address - Phone:409-370-3770
Mailing Address - Fax:
Practice Address - Street 1:17043 EL CAMINO REAL STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2600
Practice Address - Country:US
Practice Address - Phone:409-370-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1154867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner