Healthcare Provider Details

I. General information

NPI: 1407226194
Provider Name (Legal Business Name): WANDA IVETTE CHACON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 BRUCE B DOWNS BLVD STE 201
WESLEY CHAPEL FL
33544-9203
US

IV. Provider business mailing address

10682 LAXER CAY LOOP
SAN ANTONIO FL
33576-7307
US

V. Phone/Fax

Practice location:
  • Phone: 813-788-8160
  • Fax: 813-355-5065
Mailing address:
  • Phone: 786-897-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN2894372
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN28943272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: