Provider Demographics
NPI:1891391306
Name:CHANNELL, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:CHANNELL
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 1:68 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MEADOW BRIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25976-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 GRAY GABLES RD
Practice Address - Street 2:
Practice Address - City:CRAWLEY
Practice Address - State:WV
Practice Address - Zip Code:24931-9738
Practice Address - Country:US
Practice Address - Phone:304-392-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant