Provider Demographics
NPI:1215606462
Name:CALLISON, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CALLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 ANGEL RAE DR
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-7017
Mailing Address - Country:US
Mailing Address - Phone:304-667-7694
Mailing Address - Fax:
Practice Address - Street 1:135 ANGEL RAE DR
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-7017
Practice Address - Country:US
Practice Address - Phone:304-667-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker