Provider Demographics
NPI:1235817354
Name:CHAPPELL, THEOTIS JR (APRN)
Entity type:Individual
Prefix:MR
First Name:THEOTIS
Middle Name:
Last Name:CHAPPELL
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 PELICAN BAY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1381
Mailing Address - Country:US
Mailing Address - Phone:386-206-8069
Mailing Address - Fax:386-206-8069
Practice Address - Street 1:1172 PELICAN BAY DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1381
Practice Address - Country:US
Practice Address - Phone:386-206-8069
Practice Address - Fax:386-206-8069
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027332363LP0808X
GARN247061363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121313700Medicaid