MEDICARE: MRS. GINA C CHMELA APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209008640	IL
2	363L00000X	Nurse Practitioner	209008640	IL

General Provider Information

NPI Number	:	1558668764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GINA C CHMELA APN

Provider Business Mailing Address
First Line	:	145 S. VIRGINIA STREET
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7226
Country	:	US
Telephone Number	:	815-444-9999
Fax Number	:	815-986-1363

Provider Business Practice Location Address
First Line	:	145 S. VIRGINIA STREET
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7226
Country	:	US
Telephone Number	:	815-444-9999
Fax Number	:	815-986-1363

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2011
Last Update Date	:	01/22/2019

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