Provider Demographics
NPI:1194483628
Name:BONNER, CHANELL
Entity type:Individual
Prefix:
First Name:CHANELL
Middle Name:
Last Name:BONNER
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 1:17301 BILTMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1649
Mailing Address - Country:US
Mailing Address - Phone:216-258-5802
Mailing Address - Fax:
Practice Address - Street 1:5 SEVERANCE CIR STE 201
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1567
Practice Address - Country:US
Practice Address - Phone:216-659-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty