Provider Demographics
NPI:1265045496
Name:CHISM, DORA L
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:L
Last Name:CHISM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-5527
Mailing Address - Country:US
Mailing Address - Phone:601-815-5658
Mailing Address - Fax:
Practice Address - Street 1:425 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-5527
Practice Address - Country:US
Practice Address - Phone:601-815-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator