Provider Demographics
NPI:1316214190
Name:WADDELL, CHELSI ANN (DC)
Entity Type:Individual
Prefix:
First Name:CHELSI
Middle Name:ANN
Last Name:WADDELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:CHELSI
Other - Middle Name:ANN
Other - Last Name:CARLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:831 W JACKSON PLAZA
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1569
Mailing Address - Country:US
Mailing Address - Phone:309-263-5698
Mailing Address - Fax:309-263-5697
Practice Address - Street 1:831 W JACKSON PLAZA
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1569
Practice Address - Country:US
Practice Address - Phone:309-263-5698
Practice Address - Fax:309-263-5697
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211259002Medicare PIN