Provider Demographics
NPI:1649987900
Name:KENNER, CHANEL GOLD
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:GOLD
Last Name:KENNER
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 1:4290 JUBILO DR
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:310-405-4267
Mailing Address - Fax:
Practice Address - Street 1:4290 JUBILO DR
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:310-405-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist