Provider Demographics
NPI:1316191745
Name:MCCULLOUGH, CORNELIA M (ARNP)
Entity type:Individual
Prefix:MRS
First Name:CORNELIA
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ARNP
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Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:1255 LILA ST
Practice Address - Street 2:UFJAX - LEM TURNER FAMILY MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3550
Practice Address - Country:US
Practice Address - Phone:904-383-1001
Practice Address - Fax:904-244-5791
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP3228512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0020486-00Medicaid
FL0020486-00Medicaid