=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629748579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH DAVIS CALLAHAN NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2021
-----------------------------------------------------
Last Update Date | 09/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 DOROTHY ST
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-7161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-285-4721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2702 WARE ST
-----------------------------------------------------
City | BLACKSHEAR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31516-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-288-0783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN278208
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------