Healthcare Provider Details

I. General information

NPI: 1942729173
Provider Name (Legal Business Name): JACQUELINE CHANNELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 EXECUTIVE DR STE 227
SAN DIEGO CA
92121-3020
US

IV. Provider business mailing address

111 STONE HARBOR WAY APT F1
DELRAY BEACH FL
33444-3407
US

V. Phone/Fax

Practice location:
  • Phone: 888-777-1945
  • Fax: 805-413-9099
Mailing address:
  • Phone: 561-445-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9278612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: