Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | MB07492500 | NJ |
N | 207Q00000X | Family Doctor | MB07492500 | NJ |
NPI | 1043280159 |
---|---|
Provider Name | Dr. Millicent K Channell |
First Address | Stratford, NJ 08084-1354 |
Second Address | Stratford, NJ 08084-1354 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2006 |
Last Update Date | 17/11/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0068381 | (05) | NJ |
I31293 | (02) | NJ |