Provider Demographics
NPI:1245866714
Name:CALLIER DORTCH, KIERRIAH
Entity type:Individual
Prefix:
First Name:KIERRIAH
Middle Name:
Last Name:CALLIER DORTCH
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 1:314 S 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7301
Mailing Address - Country:US
Mailing Address - Phone:404-688-9300
Mailing Address - Fax:
Practice Address - Street 1:314 S 25TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7301
Practice Address - Country:US
Practice Address - Phone:404-688-9300
Practice Address - Fax:228-202-2300
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-148061163W00000X, 363LW0102X
MN2472837163W00000X
MI4704344323163W00000X
FLAPRN11017591363LW0102X
GAGAA-NP001530363LW0102X
MS905181363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health