Provider Demographics
NPI:1609839430
Name:CALLAHAN, MICHELLE L (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 S GARRISON
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-5215
Mailing Address - Country:US
Mailing Address - Phone:417-359-8646
Mailing Address - Fax:417-359-8344
Practice Address - Street 1:433 S GARRISON
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-5215
Practice Address - Country:US
Practice Address - Phone:417-667-6015
Practice Address - Fax:417-667-3007
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001008786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425316130Medicaid
MOH75000001OtherMEDICARE
MO425316130Medicaid