Healthcare Provider Details

I. General information

NPI: 1467719518
Provider Name (Legal Business Name): KETURAH CHAMBLISS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 S US HIGHWAY 1 STE 2
PORT ST LUCIE FL
34952-6407
US

IV. Provider business mailing address

5407 EAGLE DR
FORT PIERCE FL
34951-2376
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: