Healthcare Provider Details

I. General information

NPI: 1962997650
Provider Name (Legal Business Name): CHELSEA LYNN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHELSEA LYNN CALLAHAN

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 BEAL PKWY N STE 105
FORT WALTON BEACH FL
32548-3926
US

IV. Provider business mailing address

362 BEAL PKWY N STE 105
FORT WALTON BEACH FL
32548-3926
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-3020
  • Fax: 850-862-1363
Mailing address:
  • Phone: 850-862-3020
  • Fax: 850-862-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberPA11842
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0860
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117653
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: