Provider Demographics
NPI:1649484411
Name:ASTALOS CHISM, LISA KAY (MS, RN, CS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:ASTALOS CHISM
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Gender:F
Credentials:MS, RN, CS
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Mailing Address - Street 1:23401 LEIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2774
Mailing Address - Country:US
Mailing Address - Phone:734-676-9800
Mailing Address - Fax:734-676-9801
Practice Address - Street 1:21090 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1602
Practice Address - Country:US
Practice Address - Phone:734-676-9800
Practice Address - Fax:734-676-9801
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704176901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner