Healthcare Provider Details

I. General information

NPI: 1780104877
Provider Name (Legal Business Name): DARESHIA F CHAMBERS-STAPLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W FAIRCHILD ST
DANVILLE IL
61832-3876
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-431-7650
  • Fax: 217-431-7634
Mailing address:
  • Phone: 217-383-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: