Provider Demographics
NPI:1629898440
Name:CHANNON, SYDNEY RAY
Entity type:Individual
Prefix:MRS
First Name:SYDNEY
Middle Name:RAY
Last Name:CHANNON
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 1:213 BOURMONT RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-0068
Mailing Address - Country:US
Mailing Address - Phone:206-310-6301
Mailing Address - Fax:
Practice Address - Street 1:213 BOURMONT RD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-0068
Practice Address - Country:US
Practice Address - Phone:206-310-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9651980163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse