Provider Demographics
NPI:1033221312
Name:CHISM, DANIELLE R (CST)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:R
Last Name:CHISM
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WELLINGTON AVE
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6132
Mailing Address - Country:US
Mailing Address - Phone:970-243-7908
Mailing Address - Fax:970-245-0656
Practice Address - Street 1:2373 G RD STE 240
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:970-243-7908
Practice Address - Fax:970-245-0656
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO87994246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist