Provider Demographics
NPI:1255717096
Name:DEDEAUX, CHAVONN L (FNP-C)
Entity type:Individual
Prefix:
First Name:CHAVONN
Middle Name:L
Last Name:DEDEAUX
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CHAVONN
Other - Middle Name:L
Other - Last Name:DEDEAUX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:4187 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-2833
Mailing Address - Country:US
Mailing Address - Phone:708-271-3973
Mailing Address - Fax:
Practice Address - Street 1:5495 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1647
Practice Address - Country:US
Practice Address - Phone:219-884-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF03240103363LF0000X
IN28246104A163W00000X
IN27071592A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse