Provider Demographics
NPI:1598535957
Name:WEATHERSPOON, CHRYSTA SHIANNE
Entity Type:Individual
Prefix:
First Name:CHRYSTA
Middle Name:SHIANNE
Last Name:WEATHERSPOON
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 1:9822 S OGLESBY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4870
Mailing Address - Country:US
Mailing Address - Phone:773-595-5154
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PL
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6603
Practice Address - Country:US
Practice Address - Phone:847-695-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator