Provider Demographics
NPI:1497351951
Name:CHACON, IRIS JULIETA (CCP)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:JULIETA
Last Name:CHACON
Suffix:
Gender:F
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17080 SAFETY ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7506
Mailing Address - Country:US
Mailing Address - Phone:239-223-9094
Mailing Address - Fax:
Practice Address - Street 1:17080 SAFETY ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7506
Practice Address - Country:US
Practice Address - Phone:239-223-9094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLP035242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC250410648010OtherDRIVER LICENSE