Provider Demographics
NPI:1316298870
Name:MCCULLOUGH, MICHAEL ALLEN (PHD, NP-BC, AP-RN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PHD, NP-BC, AP-RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1578
Mailing Address - Country:US
Mailing Address - Phone:770-460-4075
Mailing Address - Fax:
Practice Address - Street 1:101 YORKTOWN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1578
Practice Address - Country:US
Practice Address - Phone:770-460-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN057553NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily