Provider Demographics
NPI:1558156513
Name:FANOUTH, CHENELLE RENEE (PHARMD)
Entity type:Individual
Prefix:
First Name:CHENELLE
Middle Name:RENEE
Last Name:FANOUTH
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7384 CODY RUN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-8035
Mailing Address - Country:US
Mailing Address - Phone:715-379-4509
Mailing Address - Fax:
Practice Address - Street 1:1415 E STATE ST STE 800
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2344
Practice Address - Country:US
Practice Address - Phone:779-696-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist