Provider Demographics
NPI:1861213662
Name:DEGRAFF, CHANELLE YVETTE (CNS)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:YVETTE
Last Name:DEGRAFF
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 N TATUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6039
Mailing Address - Country:US
Mailing Address - Phone:480-213-3908
Mailing Address - Fax:
Practice Address - Street 1:14635 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-0456
Practice Address - Country:US
Practice Address - Phone:480-213-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X
AZ133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education