Provider Demographics
NPI:1316361223
Name:CHISUM, REGINA DIANE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:DIANE
Last Name:CHISUM
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 HOSPITAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2008
Mailing Address - Country:US
Mailing Address - Phone:940-665-6679
Mailing Address - Fax:940-665-8958
Practice Address - Street 1:1902 HOSPITAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2008
Practice Address - Country:US
Practice Address - Phone:940-665-6679
Practice Address - Fax:940-665-8958
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX736657363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health