Provider Demographics
NPI:1770457632
Name:WISHNUFF, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:WISHNUFF
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 1:4708 PROVIDENCE WOODS CIR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3708
Mailing Address - Country:US
Mailing Address - Phone:636-352-7789
Mailing Address - Fax:
Practice Address - Street 1:4708 PROVIDENCE WOODS CIR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3708
Practice Address - Country:US
Practice Address - Phone:636-352-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025043137363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health