Provider Demographics
NPI:1285710467
Name:CHISHOLM, DEREK A (LPN)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 CLIFF POINT CIR E
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-8108
Mailing Address - Country:US
Mailing Address - Phone:719-260-7939
Mailing Address - Fax:
Practice Address - Street 1:875 W MORENO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1731
Practice Address - Country:US
Practice Address - Phone:719-572-6200
Practice Address - Fax:719-572-6427
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31420164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse