Provider Demographics
NPI:1750103651
Name:HERNANDEZ, CALYSTA NATELLE
Entity type:Individual
Prefix:
First Name:CALYSTA
Middle Name:NATELLE
Last Name:HERNANDEZ
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 1:106 BROAD ST # 301
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2713
Mailing Address - Country:US
Mailing Address - Phone:714-309-4826
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-3161
Practice Address - Country:US
Practice Address - Phone:865-862-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8751225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant