Provider Demographics
NPI:1205201035
Name:VAN DAM, CALLI JEAN (AGPCNP)
Entity type:Individual
Prefix:MS
First Name:CALLI
Middle Name:JEAN
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10215 FERNWOOD RD
Mailing Address - Street 2:STE 506
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1184
Mailing Address - Country:US
Mailing Address - Phone:301-530-1010
Mailing Address - Fax:301-897-8597
Practice Address - Street 1:10215 FERNWOOD RD
Practice Address - Street 2:STE 506
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1184
Practice Address - Country:US
Practice Address - Phone:301-530-1010
Practice Address - Fax:301-897-8597
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1032619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024175551OtherLICENSE
MDAC002241OtherLICENSE