Basic Information
| Provider Information | |||||||||
| NPI: | 1649791047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALLA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 310 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187502457 | ||||||||
| FaxNumber: | 7122010340 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187502457 | ||||||||
| FaxNumber: | 7122010340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2017 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2187502457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CNP | ||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | CNP3970 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.