Provider Demographics
NPI:1598529448
Name:CHISOM, KELSI NICOLE (FNP)
Entity Type:Individual
Prefix:MS
First Name:KELSI
Middle Name:NICOLE
Last Name:CHISOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4040 HIGHWAY 17 UNIT 202
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5098
Practice Address - Country:US
Practice Address - Phone:843-235-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28364363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily