Healthcare Provider Details

I. General information

NPI: 1174020259
Provider Name (Legal Business Name): CHENNELLE THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 E LOHMAN AVE
LAS CRUCES NM
88011-8267
US

IV. Provider business mailing address

4401 E LOHMAN AVE
LAS CRUCES NM
88011-8267
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9077
  • Fax: 575-532-9221
Mailing address:
  • Phone: 575-532-9077
  • Fax: 575-532-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD20240035
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: