Provider Demographics
NPI:1962015552
Name:ODEGARD, CALLIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:
Other - Last Name:LUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:500 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 FOREST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5554
Practice Address - Country:US
Practice Address - Phone:615-556-6523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10311-33207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine