Provider Demographics
NPI:1386752566
Name:CALLICOAT, ANITA LOUISE (NP-C)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
Last Name:CALLICOAT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 OAKWOOD ESTS
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9730
Mailing Address - Country:US
Mailing Address - Phone:304-610-7488
Mailing Address - Fax:
Practice Address - Street 1:3501 MACCORKLE AVE SE # 151
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1419
Practice Address - Country:US
Practice Address - Phone:866-460-3567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV208017790OtherUMWA
WV20801779000OtherWV WORKERS COMP
WV613154600OtherBLACL LUNG
P00720801OtherRAILROAD
OH2821307Medicaid
WV3810006599Medicaid
WV208017790OtherUMWA
P00720801OtherRAILROAD
WV3810006599Medicaid