Healthcare Provider Details

I. General information

NPI: 1639736770
Provider Name (Legal Business Name): KATIE CALLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 280
SAINT LOUIS MO
63128-3287
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 280
SAINT LOUIS MO
63128-3287
US

V. Phone/Fax

Practice location:
  • Phone: 314-892-6565
  • Fax: 314-892-4828
Mailing address:
  • Phone: 314-892-6565
  • Fax: 314-892-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018023212
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: