Basic Information
Provider Information | |||||||||
NPI: | 1043785991 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FELIX | ||||||||
FirstName: | CHELSEA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHULEUERLOLUE | ||||||||
OtherFirstName: | CHELSEA | ||||||||
OtherMiddleName: | UCHENNA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6550 | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136016550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157827445 | ||||||||
FaxNumber: | 3157791184 | ||||||||
Practice Location | |||||||||
Address1: | 167 POLK ST STE 300 | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136012770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157827445 | ||||||||
FaxNumber: | 3157791184 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2018 | ||||||||
LastUpdateDate: | 10/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 759028 | NY | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 3372621 | 05 | NY |   | MEDICAID |