Basic Information
| Provider Information | |||||||||
| NPI: | 1386752566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLICOAT | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 OAKWOOD ESTS | ||||||||
| Address2: | |||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046107488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 MACCORKLE AVE SE # 151 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664603567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 59045 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 208017790 | 01 | WV | UMWA | OTHER | 20801779000 | 01 | WV | WV WORKERS COMP | OTHER | 613154600 | 01 | WV | BLACL LUNG | OTHER | P00720801 | 01 | RAILROAD | OTHER | 2821307 | 05 | OH | MEDICAID | 3810006599 | 05 | WV | MEDICAID |