Provider Demographics
NPI:1851008718
Name:CHISLOM, CHANNEL DEVON
Entity Type:Individual
Prefix:
First Name:CHANNEL
Middle Name:DEVON
Last Name:CHISLOM
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 1:4193 FLAT ROCK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-7111
Mailing Address - Country:US
Mailing Address - Phone:747-202-9158
Mailing Address - Fax:
Practice Address - Street 1:4193 FLAT ROCK DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-7111
Practice Address - Country:US
Practice Address - Phone:747-202-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver