Provider Demographics
NPI:1295004216
Name:SAWYER, KALISTA A (DC)
Entity type:Individual
Prefix:DR
First Name:KALISTA
Middle Name:A
Last Name:SAWYER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KALISTA
Other - Middle Name:A
Other - Last Name:HOUSELOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:960 STUART CT
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-5155
Mailing Address - Country:US
Mailing Address - Phone:920-710-1811
Mailing Address - Fax:
Practice Address - Street 1:652 W RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1254
Practice Address - Country:US
Practice Address - Phone:920-710-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4819-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100020115Medicaid