Provider Demographics
NPI:1780301671
Name:CALLISTER, MARY CLARICE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CLARICE
Last Name:CALLISTER
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 1:5670 N KERCLIFFE CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-2050
Mailing Address - Country:US
Mailing Address - Phone:208-608-8114
Mailing Address - Fax:
Practice Address - Street 1:5670 N KERCLIFFE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2050
Practice Address - Country:US
Practice Address - Phone:208-608-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health