Provider Demographics
NPI:1427821461
Name:CHISOLM, LATOYA L
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:L
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 1:155 WILLOWBROOK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7033
Mailing Address - Country:US
Mailing Address - Phone:347-850-3666
Mailing Address - Fax:
Practice Address - Street 1:155 WILLOWBROOK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7033
Practice Address - Country:US
Practice Address - Phone:347-850-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist