Provider Demographics
NPI:1407639016
Name:NGUYEN, CHANELL (OD)
Entity Type:Individual
Prefix:MS
First Name:CHANELL
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N RED BRUSH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4409
Mailing Address - Country:US
Mailing Address - Phone:316-300-0598
Mailing Address - Fax:
Practice Address - Street 1:2020 N WOODLAWN ST STE 390
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-1883
Practice Address - Country:US
Practice Address - Phone:316-682-9891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist