Healthcare Provider Details

I. General information

NPI: 1386752566
Provider Name (Legal Business Name): ANITA LOUISE CALLICOAT NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 MACCORKLE AVE SE # 151
CHARLESTON WV
25304-1419
US

IV. Provider business mailing address

105 OAKWOOD ESTS
SCOTT DEPOT WV
25560-9730
US

V. Phone/Fax

Practice location:
  • Phone: 866-460-3567
  • Fax:
Mailing address:
  • Phone: 304-610-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number59045
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: