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General NPI Number Information
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NPI Number | 1275192494
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Entity Type | Individual
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Provider Name | CHARDONNAY HENRY
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Gender | Female
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Dates
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Enumeration Date | 06/11/2019
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Last Update Date | 06/15/2024
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Provider Practice Location Address
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Address Line | 7627 LAKE STREET SUITE 206 PMB 1005
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City | RIVER FOREST
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State | IL
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Zip | 60305-1878
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Country | US
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Telephone | 708-316-9951
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Fax | 708-367-6934
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Provider Business Mailing Address
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Address Line | 7627 LAKE STREET SUITE 206 PMB 1005
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City | RIVER FOREST
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State | IL
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Zip | 60305-1878
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Country | US
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Telephone | 708-316-9951
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Fax | 708-367-6934
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number | KAESVF8SO6
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License Number State | IL
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