Provider Demographics
NPI:1710574371
Name:DUNFORD, CHANELLA
Entity Type:Individual
Prefix:
First Name:CHANELLA
Middle Name:
Last Name:DUNFORD
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 1:301 W 1ST ST STE 204
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-3026
Mailing Address - Country:US
Mailing Address - Phone:937-838-4884
Mailing Address - Fax:
Practice Address - Street 1:301 W 1ST ST STE 204
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-3026
Practice Address - Country:US
Practice Address - Phone:937-838-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0196475Medicaid