Provider Demographics
NPI:1245791094
Name:CALLICUTT, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CALLICUTT
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 1:125 ALLEN CV
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-8001
Mailing Address - Country:US
Mailing Address - Phone:870-636-9593
Mailing Address - Fax:870-559-2803
Practice Address - Street 1:110 BLOCK ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1956
Practice Address - Country:US
Practice Address - Phone:870-636-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2253207323747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225320732Medicaid