Provider Demographics
NPI:1457986929
Name:BATES, CHANELLE CHRISTINE (APN)
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:CHRISTINE
Last Name:BATES
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CHANELLE
Other - Middle Name:CHRISTINE
Other - Last Name:MACLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:504 E KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-2554
Mailing Address - Country:US
Mailing Address - Phone:904-729-8022
Mailing Address - Fax:
Practice Address - Street 1:1203 W AUGUSTA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4327
Practice Address - Country:US
Practice Address - Phone:773-248-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily