Provider Demographics
NPI:1063979094
Name:NWAGBO, CALLISTA
Entity type:Individual
Prefix:
First Name:CALLISTA
Middle Name:
Last Name:NWAGBO
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 1:10826 SWAN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-3203
Mailing Address - Country:US
Mailing Address - Phone:346-754-4677
Mailing Address - Fax:
Practice Address - Street 1:10826 SWAN GLEN DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-3203
Practice Address - Country:US
Practice Address - Phone:346-754-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX954199163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse