Provider Demographics
NPI:1124904149
Name:FAUWTS-WATKINS, CHANEL BRIANA
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:BRIANA
Last Name:FAUWTS-WATKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5942
Mailing Address - Country:US
Mailing Address - Phone:951-358-6572
Mailing Address - Fax:951-737-2783
Practice Address - Street 1:2813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5942
Practice Address - Country:US
Practice Address - Phone:951-358-6572
Practice Address - Fax:951-737-2783
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-QLOFZE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist