Healthcare Provider Details

I. General information

NPI: 1497528491
Provider Name (Legal Business Name): NICOLE CHISUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR
DECATUR TX
76234-3843
US

IV. Provider business mailing address

369 WISE RD
DECATUR TX
76234-7643
US

V. Phone/Fax

Practice location:
  • Phone: 940-626-2110
  • Fax:
Mailing address:
  • Phone: 940-393-3215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1133002
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: