Provider Demographics
NPI:1962997650
Name:RUSSELL, CHELSEA LYNN
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:LYNN
Other - Last Name:CALLAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:362 BEAL PKWY N STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-3926
Mailing Address - Country:US
Mailing Address - Phone:850-862-3020
Mailing Address - Fax:850-862-1363
Practice Address - Street 1:362 BEAL PKWY N STE 105
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-3926
Practice Address - Country:US
Practice Address - Phone:850-862-3020
Practice Address - Fax:850-862-1363
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11842207K00000X
NDPAC0860363A00000X
FLPA9117653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology