Provider Demographics
NPI:1851566905
Name:TYRELL CHAMBERS, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:TYRELL CHAMBERS
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 1:728 S ENDEAVOUR DR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5167
Mailing Address - Country:US
Mailing Address - Phone:407-462-5613
Mailing Address - Fax:407-699-4255
Practice Address - Street 1:728 S ENDEAVOUR DR
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5167
Practice Address - Country:US
Practice Address - Phone:407-462-5613
Practice Address - Fax:407-699-4255
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18307100308253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230569100Medicaid