Provider Demographics
NPI:1568845295
Name:CHAE, JIYOUNG
Entity Type:Individual
Prefix:
First Name:JIYOUNG
Middle Name:
Last Name:CHAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5777
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5777
Mailing Address - Country:US
Mailing Address - Phone:865-246-2104
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28193970A163W00000X
IN71005808A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000964485OtherANTHEM PROVIDER PIN NUMBER
IN201323610Medicaid
IN201323610Medicaid
INP01671037Medicare PIN