Provider Demographics
NPI:1871834200
Name:CHAMNESS, KYLE MICHAEL (PTA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MICHAEL
Last Name:CHAMNESS
Suffix:
Gender:M
Credentials:PTA
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 125
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:IL
Mailing Address - Zip Code:62949-0125
Mailing Address - Country:US
Mailing Address - Phone:618-201-4121
Mailing Address - Fax:
Practice Address - Street 1:374 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3962
Practice Address - Country:US
Practice Address - Phone:618-453-1292
Practice Address - Fax:618-453-4290
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005944225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant