Provider Demographics
NPI:1639465982
Name:CHENNELL, ALICIA R (MD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:CHENNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-2845
Mailing Address - Country:US
Mailing Address - Phone:620-504-5996
Mailing Address - Fax:888-263-5552
Practice Address - Street 1:1101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460
Practice Address - Country:US
Practice Address - Phone:620-504-5996
Practice Address - Fax:888-263-5552
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36397207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201096280AMedicaid