Healthcare Provider Details

I. General information

NPI: 1194839126
Provider Name (Legal Business Name): JEANIE CHAMNESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 S MARSHALL AVE
MC LEANSBORO IL
62859-1213
US

IV. Provider business mailing address

PO BOX 429
MC LEANSBORO IL
62859-0429
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-2361
  • Fax: 186-433-9176
Mailing address:
  • Phone: 618-643-2361
  • Fax: 618-643-3917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002619
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: