Healthcare Provider Details

I. General information

NPI: 1659353944
Provider Name (Legal Business Name): PAIGE V CHISOLM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

IV. Provider business mailing address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-6011
  • Fax:
Mailing address:
  • Phone: 601-833-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR855262
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: