Provider Demographics
NPI:1609907914
Name:CHAMBERLAIN, MELISSA IRENE (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:IRENE
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16700 SE PEAR ST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-2177
Mailing Address - Country:US
Mailing Address - Phone:850-693-2543
Mailing Address - Fax:
Practice Address - Street 1:16700 SE PEAR ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-2177
Practice Address - Country:US
Practice Address - Phone:850-693-2543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2980662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308230000Medicaid
FLAB631ZMedicare PIN