=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457986929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANELLE CHRISTINE BATES APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2020
-----------------------------------------------------
Last Update Date | 04/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 W AUGUSTA BLVD STE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-248-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 E KANSAS ST
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61603-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-729-8022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209020978
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------