Provider Demographics
NPI:1932413218
Name:DILLARD, CHANELLE ARDELL (LPN)
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:ARDELL
Last Name:DILLARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 PARKER KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6210
Mailing Address - Country:US
Mailing Address - Phone:614-439-6017
Mailing Address - Fax:
Practice Address - Street 1:3685 PARKER KNOLL LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6210
Practice Address - Country:US
Practice Address - Phone:614-439-6017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140340164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2878257Medicaid