Provider Demographics
NPI:1487205654
Name:CHISOLM, TIERA
Entity Type:Individual
Prefix:
First Name:TIERA
Middle Name:
Last Name:CHISOLM
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 1:1704 MARY BETH DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-7833
Mailing Address - Country:US
Mailing Address - Phone:904-888-4597
Mailing Address - Fax:
Practice Address - Street 1:1704 MARY BETH DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-7833
Practice Address - Country:US
Practice Address - Phone:904-888-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT66081183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician