Provider Demographics
NPI:1215477070
Name:CULPEPPER, SHYLA (LMP)
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:
Last Name:CULPEPPER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4756
Mailing Address - Country:US
Mailing Address - Phone:360-442-1047
Mailing Address - Fax:
Practice Address - Street 1:1223 17TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2905
Practice Address - Country:US
Practice Address - Phone:360-353-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60533822405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60533822OtherLMP