Provider Demographics
NPI:1265576185
Name:MANHART, CHANTAL ANNETTE-VAN HOUTEN (ARNP)
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:ANNETTE-VAN HOUTEN
Last Name:MANHART
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 BETHANY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3124
Mailing Address - Country:US
Mailing Address - Phone:815-899-8080
Mailing Address - Fax:815-899-8002
Practice Address - Street 1:1675 BETHANY RD
Practice Address - Street 2:SUITE C
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3124
Practice Address - Country:US
Practice Address - Phone:815-899-8080
Practice Address - Fax:815-899-8002
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006994363LF0000X, 363LX0001X
IAA-087782363LF0000X
IAF-087782363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.006994OtherILLINOIS LICENSE NUMBER
IAF-087782 OR A-087782OtherIOWA LICENSE NUMBER