Provider Demographics
NPI:1639736770
Name:CALLIS, KATIE (NP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CALLIS
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 1:1240 INDIA ST UNIT 1401
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8552
Mailing Address - Country:US
Mailing Address - Phone:636-232-7999
Mailing Address - Fax:
Practice Address - Street 1:4829 CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-2706
Practice Address - Country:US
Practice Address - Phone:858-273-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily