Provider Demographics
NPI:1982389052
Name:CHISOLM, KELSIE RAE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:RAE
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 1:15043 HIGHWAY 503
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-9680
Mailing Address - Country:US
Mailing Address - Phone:601-479-5890
Mailing Address - Fax:
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906102363L00000X
MS897243163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse