Healthcare Provider Details

I. General information

NPI: 1558162719
Provider Name (Legal Business Name): CHE-IA D DONELY-WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W 46TH AVE
GARY IN
46408-3905
US

IV. Provider business mailing address

141 W 46TH AVE
GARY IN
46408-3905
US

V. Phone/Fax

Practice location:
  • Phone: 312-785-3863
  • Fax:
Mailing address:
  • Phone: 312-785-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License Number041.4622619
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number041.462619
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number28279273A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: