Provider Demographics
NPI:1194839126
Name:CHAMNESS, JEANIE (PA-C)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:CHAMNESS
Suffix:
Gender:F
Credentials:PA-C
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 429
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-0429
Mailing Address - Country:US
Mailing Address - Phone:618-643-2361
Mailing Address - Fax:618-643-3917
Practice Address - Street 1:611 S MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1213
Practice Address - Country:US
Practice Address - Phone:618-643-2361
Practice Address - Fax:186-433-9176
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002619363A00000X
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
047016OtherHEALTH ALLIANCE
IL148969Medicaid
080137051OtherRAILROAD MEDICARE
10019630OtherBCBS
334689OtherHEALTH LINK
10019630OtherBCBS
334689OtherHEALTH LINK