Healthcare Provider Details

I. General information

NPI: 1245713064
Provider Name (Legal Business Name): CHELSEA LYNNEA WICHTNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S CRESCENT ST STE B
GILMAN IL
60938-1518
US

IV. Provider business mailing address

200 E FAIRMAN AVE
WATSEKA IL
60970-1644
US

V. Phone/Fax

Practice location:
  • Phone: 815-265-8889
  • Fax:
Mailing address:
  • Phone: 815-432-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041.405529
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018536
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: