Provider Demographics
NPI:1043857493
Name:JANET, CALLIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:LYNN
Last Name:JANET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S MICHIGAN AVE APT 1203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3720
Mailing Address - Country:US
Mailing Address - Phone:312-767-3244
Mailing Address - Fax:
Practice Address - Street 1:900 RAND RD STE 120
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-2359
Practice Address - Country:US
Practice Address - Phone:312-767-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020005533363A00000X
IL085008010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant