MEDICARE: CHANELLE YVETTE DEGRAFF CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist
2	133N00000X	Nutritionist		AZ

General Provider Information

NPI Number	:	1861213662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANELLE YVETTE DEGRAFF CNS

Provider Business Mailing Address
First Line	:	11201 N TATUM BLVD STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6039
Country	:	US
Telephone Number	:	480-213-3908
Fax Number	:

Provider Business Practice Location Address
First Line	:	14635 S 4TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-0456
Country	:	US
Telephone Number	:	480-213-3908
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	10/23/2024

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