Provider Demographics
NPI:1265979108
Name:HERBERTZ, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:HERBERTZ
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 1:10610 PENTECOST RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9433
Mailing Address - Country:US
Mailing Address - Phone:317-370-5315
Mailing Address - Fax:
Practice Address - Street 1:5026 W US 52
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163
Practice Address - Country:US
Practice Address - Phone:317-861-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28209345A363LF0000X
IN71007579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily