Provider Demographics
NPI:1154742351
Name:CHANCELLOR, CHARLOTTE RENEE (OTR/L)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:RENEE
Last Name:CHANCELLOR
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 W 114TH ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2178
Mailing Address - Country:US
Mailing Address - Phone:918-629-1025
Mailing Address - Fax:
Practice Address - Street 1:9810 E 42ND ST STE 110
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-3675
Practice Address - Country:US
Practice Address - Phone:918-828-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT151251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health