Provider Demographics
NPI:1558035816
Name:DRUCKER, CHANEL
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:DRUCKER
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 1:2960 E. ST. LUKE'S STREET SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9099
Mailing Address - Country:US
Mailing Address - Phone:208-378-4264
Mailing Address - Fax:
Practice Address - Street 1:2960 E. ST. LUKE'S STREET SUITE 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9005
Practice Address - Country:US
Practice Address - Phone:208-378-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-11-04
Deactivation Date:2021-09-29
Deactivation Code:
Reactivation Date:2021-10-18
Provider Licenses
StateLicense IDTaxonomies
IDD-1288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered