Healthcare Provider Details

I. General information

NPI: 1346075942
Provider Name (Legal Business Name): CHILDREN'S HEALTHCARE OF BREVARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 W EAU GALLIE BLVD STE 4
MELBOURNE FL
32935-3114
US

IV. Provider business mailing address

2351 W EAU GALLIE BLVD STE 4
MELBOURNE FL
32935-3114
US

V. Phone/Fax

Practice location:
  • Phone: 321-775-0477
  • Fax: 321-775-0476
Mailing address:
  • Phone: 321-775-0477
  • Fax: 321-775-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGARET WITZLEB
Title or Position: NURSE-PRACTITIONER OWNER
Credential: ARNP
Phone: 321-775-0477