Provider Demographics
NPI:1730786229
Name:CONYAC, CALISTA ANN
Entity type:Individual
Prefix:
First Name:CALISTA
Middle Name:ANN
Last Name:CONYAC
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 1:1211 W SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-1553
Mailing Address - Country:US
Mailing Address - Phone:712-215-3479
Mailing Address - Fax:
Practice Address - Street 1:908 BENTON AVENUE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:IA
Practice Address - Zip Code:50841-5160
Practice Address - Country:US
Practice Address - Phone:712-215-3479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health