Provider Demographics
NPI:1659734515
Name:MCCALLA, WINIFRIED
Entity Type:Individual
Prefix:
First Name:WINIFRIED
Middle Name:
Last Name:MCCALLA
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 1:1104 BARTOW RD # H85
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5850
Mailing Address - Country:US
Mailing Address - Phone:863-812-7724
Mailing Address - Fax:
Practice Address - Street 1:1104 BARTOW RD # H85
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5850
Practice Address - Country:US
Practice Address - Phone:863-812-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL102424376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010465800Medicaid