Provider Demographics
NPI:1124896980
Name:SELF, CALLIE HALL (AGNP)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:HALL
Last Name:SELF
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:FRANCES
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGNP
Mailing Address - Street 1:104 BURNEY DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6621
Mailing Address - Country:US
Mailing Address - Phone:601-987-8200
Mailing Address - Fax:601-987-8211
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:601-987-8211
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906256363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner