Healthcare Provider Details

I. General information

NPI: 1700824638
Provider Name (Legal Business Name): SHANNON DRE CHISHOLM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 N WILLIAMSON BLVD
DAYTONA BEACH FL
32114-7185
US

IV. Provider business mailing address

PO BOX 7410884
CHICAGO IL
60674-0884
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax: 702-977-1496
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107966
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA02625
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: