Provider Demographics
NPI:1861182115
Name:MCCALLON, KORNNISA (FNP)
Entity type:Individual
Prefix:
First Name:KORNNISA
Middle Name:
Last Name:MCCALLON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1032
Mailing Address - Street 2:
Mailing Address - City:HELENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:92342-1032
Mailing Address - Country:US
Mailing Address - Phone:442-319-9630
Mailing Address - Fax:
Practice Address - Street 1:16167 SISKIYOU RD STE A
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-0837
Practice Address - Country:US
Practice Address - Phone:760-242-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023549207VX0201X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care