Provider Demographics
NPI:1710281233
Name:CALLOWAY, BREIDI A (NP)
Entity Type:Individual
Prefix:
First Name:BREIDI
Middle Name:A
Last Name:CALLOWAY
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:NOR 8302E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-3105
Practice Address - Fax:323-865-0061
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18343261QP2300X, 261QX0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18762OtherGROUP MEDICARE
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDICAL