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General NPI Number Information
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NPI Number | 1558824912
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Entity Type | Individual
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Provider Name | AVERY CAMILLE CHISHOLM MD
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Gender | Female
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Dates
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Enumeration Date | 04/11/2019
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 462626 STATE ROAD 200 STE 300
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City | YULEE
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State | FL
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Zip | 32097-5516
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Country | US
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Telephone | 904-398-7205
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Fax |
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Provider Business Mailing Address
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Address Line | 4800 BELFORT RD
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City | JACKSONVILLE
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State | FL
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Zip | 32256-6004
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Country | US
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Telephone | 904-504-8195
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | ME175195
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License Number State | FL
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