Provider Demographics
NPI:1881360782
Name:ENRIQUEZ, CHANNELL NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:CHANNELL
Middle Name:NICOLE
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 BLOSSOM CREST ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-9285
Mailing Address - Country:US
Mailing Address - Phone:805-814-4392
Mailing Address - Fax:
Practice Address - Street 1:1725 BLOSSOM CREST ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93314-9285
Practice Address - Country:US
Practice Address - Phone:805-814-4392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48391225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant