Healthcare Provider Details

I. General information

NPI: 1043280159
Provider Name (Legal Business Name): MILLICENT K CHANNELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MILLICENT A KING D.O.

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E LAUREL RD STE 1700
STRATFORD NJ
08084-1354
US

IV. Provider business mailing address

42 E LAUREL RD STE 1700
STRATFORD NJ
08084-1354
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-7010
  • Fax: 856-566-6956
Mailing address:
  • Phone: 856-566-7010
  • Fax: 856-566-6956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMB07492500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB07492500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: