Provider Demographics
NPI:1053900647
Name:SMITH, CHANELLE (RN)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9248 PIEDMONT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1727
Mailing Address - Country:US
Mailing Address - Phone:248-914-2939
Mailing Address - Fax:
Practice Address - Street 1:9248 PIEDMONT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1727
Practice Address - Country:US
Practice Address - Phone:248-914-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704310023163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection Control
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704310023OtherREGISTERED NURSE LICENSE NUMBER