Basic Information
| Provider Information | |||||||||
| NPI: | 1285093062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUKWUMA | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1545 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329624312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Practice Location | |||||||||
| Address1: | 13505 US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9296627 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | APRN9296627 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | APRN9296627 | 01 | FL | STATE LICENSE | OTHER |