Provider Demographics
NPI:1043083082
Name:KNOLLENBERG, CHEYANNE JADE
Entity type:Individual
Prefix:
First Name:CHEYANNE
Middle Name:JADE
Last Name:KNOLLENBERG
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 1:12016 N 200TH ST
Mailing Address - Street 2:
Mailing Address - City:OBLONG
Mailing Address - State:IL
Mailing Address - Zip Code:62449-2525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OBLONG
Practice Address - State:IL
Practice Address - Zip Code:62449-1161
Practice Address - Country:US
Practice Address - Phone:618-592-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist