Provider Demographics
NPI:1831709526
Name:BROCKETT, CALLIE ROSEANN (DC)
Entity type:Individual
Prefix:DR
First Name:CALLIE
Middle Name:ROSEANN
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:CALLIE
Other - Middle Name:ROSEANN
Other - Last Name:MILLSAP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:40 VILLAGE PLZ STE A
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 VILLAGE PLZ STE A
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2886
Practice Address - Country:US
Practice Address - Phone:620-624-2702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-06071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor