Provider Demographics
NPI:1588141535
Name:CULLERTON, SARAH SAMAYA (LAC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:SAMAYA
Last Name:CULLERTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4668
Mailing Address - Country:US
Mailing Address - Phone:831-588-9581
Mailing Address - Fax:
Practice Address - Street 1:200 7TH AVE STE 135
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4670
Practice Address - Country:US
Practice Address - Phone:831-588-9581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18086171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18086OtherCALIFORNIA ACUPUNCTURE BOARD