Provider Demographics
NPI:1689389876
Name:NUNNALLY-RICHARDSON, CHALENCIA IDALIA
Entity Type:Individual
Prefix:
First Name:CHALENCIA
Middle Name:IDALIA
Last Name:NUNNALLY-RICHARDSON
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 1:1047 N BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-3008
Mailing Address - Country:US
Mailing Address - Phone:662-629-0703
Mailing Address - Fax:
Practice Address - Street 1:1047 N BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-3008
Practice Address - Country:US
Practice Address - Phone:662-629-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS338047164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse