Provider Demographics
NPI:1376004341
Name:MUZQUIZ, CALLISTA
Entity Type:Individual
Prefix:
First Name:CALLISTA
Middle Name:
Last Name:MUZQUIZ
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 1:6376 EMILY DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY40019163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse