Basic Information
| Provider Information | |||||||||
| NPI: | 1689630055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP, APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLAZO-CAMACHO | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PNNP, RN, C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 770 NORTHPOINT PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334071901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618025357 | ||||||||
| FaxNumber: | 5612757547 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 45TH ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618410911 | ||||||||
| FaxNumber: | 5616308007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/29/2007 | ||||||||
| NPIReactivationDate: | 12/03/2007 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP1700X | 26NJ00058000 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Perinatal | 363LP1700X | ARNP9429883 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Perinatal |
ID Information
| ID | Type | State | Issuer | Description | 0036111 | 05 | NJ | MEDICAID | 101042200 | 05 | FL | MEDICAID |