Provider Demographics
NPI:1063759181
Name:MCCULLOUGH, LYAN LOVE G (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LYAN LOVE
Middle Name:G
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LYAN
Other - Middle Name:
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1447 STEARNS WHARF RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3566
Mailing Address - Country:US
Mailing Address - Phone:619-259-8933
Mailing Address - Fax:
Practice Address - Street 1:502 EUCLID AVE STE 200
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2984
Practice Address - Country:US
Practice Address - Phone:619-434-4019
Practice Address - Fax:619-434-4023
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA779235163W00000X
CA95028990363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse