Provider Demographics
NPI:1457663106
Name:MOMON-NELSON, CHAVONE DANTRELL (DO)
Entity Type:Individual
Prefix:
First Name:CHAVONE
Middle Name:DANTRELL
Last Name:MOMON-NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CHAVONE
Other - Middle Name:DANTRELL
Other - Last Name:MOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:409 SOUTH SECOND STREET
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 JENNIFER CT STE B
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-7694
Practice Address - Country:US
Practice Address - Phone:717-218-9830
Practice Address - Fax:717-218-9833
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD442418207V00000X
PATEMP LICENSE207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025762400003Medicaid
PA440771OtherMLHC AA #