Basic Information
| Provider Information | |||||||||
| NPI: | 1649484411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASTALOS CHISM | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | M.S, R.N., C.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23401 LEIGHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WOODHAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346769800 | ||||||||
| FaxNumber: | 7346769801 | ||||||||
| Practice Location | |||||||||
| Address1: | 21090 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | WOODHAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481831602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346769800 | ||||||||
| FaxNumber: | 7346769801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704176901 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.