1083202584 NPI number — LACEY MIKELLE CHARBONNEAU PHARMD, BCGP

Table of content: LACEY MIKELLE CHARBONNEAU PHARMD, BCGP (NPI 1083202584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083202584 NPI number — LACEY MIKELLE CHARBONNEAU PHARMD, BCGP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARBONNEAU
Provider First Name:
LACEY
Provider Middle Name:
MIKELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, BCGP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083202584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 6TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33881-4062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 6TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33881-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-993-3592
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS53336 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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