Healthcare Provider Details

I. General information

NPI: 1982384848
Provider Name (Legal Business Name): CHANEL RENEE NETTLE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE STE 660&470
ORANGE CA
92868-4231
US

IV. Provider business mailing address

1120 W LA VETA AVE STE 660&470
ORANGE CA
92868-4231
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1982384848
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1982384848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: