Provider Demographics
NPI:1972878965
Name:DURHAM, CALLIE DEE (APRN)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:DEE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:DEE
Other - Last Name:KITTLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:207 SPARKS AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3739
Mailing Address - Country:US
Mailing Address - Phone:812-280-7063
Mailing Address - Fax:812-218-8557
Practice Address - Street 1:207 SPARKS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3739
Practice Address - Country:US
Practice Address - Phone:812-280-7063
Practice Address - Fax:812-218-8557
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007379363LW0102X
IN71004842A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71004842AOtherLICENSE
KY7100202270Medicaid