Basic Information
| Provider Information | |||||||||
| NPI: | 1932669199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISUM | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10514 RACETRACK RD STE G | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218113241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109732301 | ||||||||
| FaxNumber: | 4109732305 | ||||||||
| Practice Location | |||||||||
| Address1: | 10514 RACETRACK RD STE G | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218113241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109732301 | ||||||||
| FaxNumber: | 4109732305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2019 | ||||||||
| LastUpdateDate: | 03/23/2019 | ||||||||
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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 | 106S00000X | MD | Y |
ID Information
| ID | Type | State | Issuer | Description | 483106300 | 05 | MD | MEDICAID |