Provider Demographics
NPI:1720556004
Name:CHANCEY, CRYSTAL
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:CHANCEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 WILLOW LN APT B6
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-1457
Mailing Address - Country:US
Mailing Address - Phone:224-440-8365
Mailing Address - Fax:
Practice Address - Street 1:2905 WILLOW LN
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-1478
Practice Address - Country:US
Practice Address - Phone:224-440-8365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health