Provider Demographics
NPI:1811362767
Name:WALCOTT, CALLAN J (CFNP)
Entity Type:Individual
Prefix:
First Name:CALLAN
Middle Name:J
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:CALLAN
Other - Middle Name:J
Other - Last Name:OLJACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:1375 W GREEN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1718
Mailing Address - Country:US
Mailing Address - Phone:269-945-7497
Mailing Address - Fax:269-945-0214
Practice Address - Street 1:1375 W GREEN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1718
Practice Address - Country:US
Practice Address - Phone:269-945-7497
Practice Address - Fax:269-945-0214
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily