Provider Demographics
NPI:1427887876
Name:PAINE, CALLIE MARIE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:MARIE
Last Name:PAINE
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 1:6200 S COUNTY ROAD 125
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5406
Mailing Address - Country:US
Mailing Address - Phone:904-885-3056
Mailing Address - Fax:
Practice Address - Street 1:340 NW COMMERCE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4709
Practice Address - Country:US
Practice Address - Phone:386-719-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034437363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care