Provider Demographics
NPI:1790416212
Name:CHACKO, CHELSEA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:CHACKO
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1500
Mailing Address - Fax:239-343-4145
Practice Address - Street 1:19511 HIGHLAND OAKS DR STE 201
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9712
Practice Address - Country:US
Practice Address - Phone:239-468-0254
Practice Address - Fax:239-343-3958
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116913363A00000X
FLPA9118144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120895000Medicaid
FL116896100Medicaid