Provider Demographics
NPI:1194487140
Name:JUSTICE, CHELSEA BREANNE
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:BREANNE
Last Name:JUSTICE
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 1:4003 CAPULLO CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6317
Mailing Address - Country:US
Mailing Address - Phone:251-978-2673
Mailing Address - Fax:
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-554-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016274363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal