Provider Demographics
NPI:1922879378
Name:SMITH, CHANELLE
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:SMITH
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 1:11 LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-6009
Mailing Address - Country:US
Mailing Address - Phone:774-251-1125
Mailing Address - Fax:
Practice Address - Street 1:11 LORRAINE RD
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-6009
Practice Address - Country:US
Practice Address - Phone:177-425-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN100398164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse