Provider Demographics
NPI:1487435699
Name:WACKELIN, EMBER LEE CHARLOTTE
Entity type:Individual
Prefix:
First Name:EMBER LEE
Middle Name:CHARLOTTE
Last Name:WACKELIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 HAMLIN ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-5116
Mailing Address - Country:US
Mailing Address - Phone:941-549-9540
Mailing Address - Fax:
Practice Address - Street 1:612 HAMLIN ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-5116
Practice Address - Country:US
Practice Address - Phone:941-549-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily