Provider Demographics
NPI:1629116546
Name:CHANEY, CHARLIE JORDAN (APN)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JORDAN
Last Name:CHANEY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1422
Mailing Address - Country:US
Mailing Address - Phone:302-984-3380
Mailing Address - Fax:302-691-0475
Practice Address - Street 1:500 W 10TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1422
Practice Address - Country:US
Practice Address - Phone:302-984-3380
Practice Address - Fax:302-691-0475
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELE-0000160364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000022914Medicaid
DEQ41184Medicare UPIN