Basic Information
| Provider Information | |||||||||
| NPI: | 1386129658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUMBLEY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2104 LEWIS TURNER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508623728 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 RACETRACK RD NW | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325474612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508642273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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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 | 106S00000X | 18-64799 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-64799 | 05 | FL | MEDICAID |