Provider Demographics
NPI:1003647041
Name:CHAVALO CAMPOS, ANA MARIA B (MSM)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA B
Last Name:CHAVALO CAMPOS
Suffix:
Gender:F
Credentials:MSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5717
Mailing Address - Country:US
Mailing Address - Phone:772-708-6792
Mailing Address - Fax:
Practice Address - Street 1:2875 NE 191ST ST STE 500
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2832
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF07240198363LP2300X
FLAPRN11034198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care