MEDICARE: KIMBEREY CALLOWAY REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	975583	TX
2	163WC0400X	Case Management Registered Nurse	975583	TX
3	163WC1500X	Community Health Registered Nurse	975583	TX
4	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	975583	TX
5	163WP0808X	Psychiatric/Mental Health Registered Nurse	975583	TX
6	171400000X	Health & Wellness Coach	975583	TX
7	171M00000X	Case Manager/Care Coordinator	975583	TX

General Provider Information

NPI Number	:	1669746772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBEREY CALLOWAY REGISTERED NURSE

Provider Business Mailing Address
First Line	:	PO BOX 15283
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-0283
Country	:	US
Telephone Number	:	682-301-2844
Fax Number	:

Provider Business Practice Location Address
First Line	:	5125 WICHITA ST
Second Line	:	15283
City	:	FORT WORTH
State	:	TX
Zip	:	76119-2541
Country	:	US
Telephone Number	:	682-301-2844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2012
Last Update Date	:	04/24/2025

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