Provider Demographics
NPI:1679836639
Name:CHAVIS, BERTHA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:CHAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BERTHA
Other - Middle Name:
Other - Last Name:OVERBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE
Mailing Address - Street 1:150 AVENUE U NW # C
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-2156
Mailing Address - Country:US
Mailing Address - Phone:407-927-1980
Mailing Address - Fax:
Practice Address - Street 1:150 AVENUE U NW # C
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2156
Practice Address - Country:US
Practice Address - Phone:407-927-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1322231164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686492979Medicaid