Healthcare Provider Details

I. General information

NPI: 1861182115
Provider Name (Legal Business Name): KORNNISA MCCALLON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16167 SISKIYOU RD STE A
APPLE VALLEY CA
92307-0837
US

IV. Provider business mailing address

PO BOX 1032
HELENDALE CA
92342-1032
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-2146
  • Fax:
Mailing address:
  • Phone: 442-319-9630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number95023549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95023549
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: