Provider Demographics
NPI:1275192494
Name:HENRY, CHARDONNAY
Entity type:Individual
Prefix:
First Name:CHARDONNAY
Middle Name:
Last Name:HENRY
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 1:7627 LAKE STREET
Mailing Address - Street 2:SUITE 206 PMB 1005
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1878
Mailing Address - Country:US
Mailing Address - Phone:708-316-9951
Mailing Address - Fax:708-367-6934
Practice Address - Street 1:7627 LAKE STREET
Practice Address - Street 2:SUITE 206 PMB 1005
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1878
Practice Address - Country:US
Practice Address - Phone:708-316-9951
Practice Address - Fax:708-367-6934
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILKAESVF8SO6224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist