Healthcare Provider Details

I. General information

NPI: 1902871312
Provider Name (Legal Business Name): DARYL CHENOWETH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7309 N KNOXVILLE AVE
PEORIA IL
61614-2085
US

IV. Provider business mailing address

1105 STERLING GLEN CC CT
NORMAL IL
61761-5297
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-0827
  • Fax: 309-683-1003
Mailing address:
  • Phone: 309-454-4617
  • Fax: 309-862-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209001108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: