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General NPI Number Information
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NPI Number | 1558156513
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Entity Type | Individual
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Provider Name | CHENELLE RENEE FANOUTH PHARMD
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Gender | Female
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Dates
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Enumeration Date | 04/10/2025
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Last Update Date | 04/10/2025
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Provider Practice Location Address
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Address Line | 1415 E STATE ST STE 800
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City | ROCKFORD
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State | IL
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Zip | 61104-2344
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Country | US
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Telephone | 779-696-9204
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Fax |
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Provider Business Mailing Address
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Address Line | 7384 CODY RUN
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City | SOUTH BELOIT
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State | IL
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Zip | 61080-8035
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Country | US
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Telephone | 715-379-4509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051297299
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License Number State | IL
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