Provider Demographics
NPI:1043280159
Name:CHANNELL, MILLICENT K (DO)
Entity type:Individual
Prefix:DR
First Name:MILLICENT
Middle Name:K
Last Name:CHANNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MILLICENT
Other - Middle Name:A
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:42 E LAUREL RD STE 1700
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-7010
Mailing Address - Fax:856-566-6956
Practice Address - Street 1:42 E LAUREL RD STE 1700
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-7010
Practice Address - Fax:856-566-6956
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB07492500204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0068381Medicaid
NJ0068381Medicaid
NJI31293Medicare UPIN