Provider Demographics
NPI:1477570455
Name:MACCALLUM, CAROL L (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:MACCALLUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 GRAY WOLF LN
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-3570
Mailing Address - Country:US
Mailing Address - Phone:720-767-4686
Mailing Address - Fax:
Practice Address - Street 1:4606 GRAY WOLF LN
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-3570
Practice Address - Country:US
Practice Address - Phone:720-767-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4174363LF0000X
TN13735363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91082056Medicaid
COC-APN4174OtherSTATE NP LICENSE
COQ68870Medicare UPIN