Provider Demographics
NPI:1346701406
Name:MCCALLISTER, CASIE
Entity type:Individual
Prefix:
First Name:CASIE
Middle Name:
Last Name:MCCALLISTER
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 1:454 S YONGE ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7501
Mailing Address - Country:US
Mailing Address - Phone:386-280-4877
Mailing Address - Fax:386-414-7227
Practice Address - Street 1:454 S YONGE ST STE 3A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7501
Practice Address - Country:US
Practice Address - Phone:386-280-4877
Practice Address - Fax:386-414-7227
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001968363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner