Provider Demographics
NPI:1902871312
Name:CHENOWETH, DARYL (CRNA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:CHENOWETH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 STERLING GLEN CC CT
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5297
Mailing Address - Country:US
Mailing Address - Phone:309-454-4617
Mailing Address - Fax:309-862-1129
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-282-0827
Practice Address - Fax:309-683-1003
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001108367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5707858OtherBCBS PROVIDER NUMBER
IL5707858OtherBCBS PROVIDER NUMBER