Provider Demographics
NPI:1104495480
Name:MCCULLOCH, RENEE ASHLEY (CRNP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ASHLEY
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023815363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine