Provider Demographics
NPI:1366208142
Name:THOMAS, CHANEL R
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:R
Last Name:THOMAS
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 1:1408 AUTUMN DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2032
Mailing Address - Country:US
Mailing Address - Phone:330-952-5359
Mailing Address - Fax:
Practice Address - Street 1:1408 AUTUMN DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2032
Practice Address - Country:US
Practice Address - Phone:330-952-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHMANAQ90987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty