Provider Demographics
NPI:1144786229
Name:LADNER, CALLISSA G (NP-C)
Entity Type:Individual
Prefix:
First Name:CALLISSA
Middle Name:G
Last Name:LADNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2559
Mailing Address - Country:US
Mailing Address - Phone:601-369-2028
Mailing Address - Fax:601-649-7805
Practice Address - Street 1:1706 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2559
Practice Address - Country:US
Practice Address - Phone:601-369-2028
Practice Address - Fax:601-649-7805
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903129207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine