Healthcare Provider Details

I. General information

NPI: 1790416212
Provider Name (Legal Business Name): CHELSEA CHACKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19511 HIGHLAND OAKS DR STE 201
ESTERO FL
33928-9712
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0254
  • Fax: 239-343-3958
Mailing address:
  • Phone: 239-424-1500
  • Fax: 239-343-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116913
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: