Provider Demographics
NPI:1497421986
Name:BUSHONG, CALLIE MARIA
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:MARIA
Last Name:BUSHONG
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 1:808 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-7100
Mailing Address - Country:US
Mailing Address - Phone:574-534-0088
Mailing Address - Fax:
Practice Address - Street 1:808 N 3RD ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7100
Practice Address - Country:US
Practice Address - Phone:574-534-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011411A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care