Provider Demographics
NPI:1336655828
Name:PETERSON, CHANTELLE EVONNE (APN)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:EVONNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13616 137TH AVE W
Mailing Address - Street 2:
Mailing Address - City:TAYLOR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61284-9710
Mailing Address - Country:US
Mailing Address - Phone:309-912-6008
Mailing Address - Fax:
Practice Address - Street 1:1007 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1317
Practice Address - Country:US
Practice Address - Phone:309-582-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016999363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health