Provider Demographics
NPI:1306643747
Name:CHISM, ANTHONY L
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:CHISM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 ROUNDROCK LN # 76104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-6550
Mailing Address - Country:US
Mailing Address - Phone:817-690-2681
Mailing Address - Fax:
Practice Address - Street 1:2305 DILLARD ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-3819
Practice Address - Country:US
Practice Address - Phone:817-690-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant