Provider Demographics
NPI:1851340558
Name:MCCULLOUGH, HEATHER MICHELLE (ARNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5367
Mailing Address - Country:US
Mailing Address - Phone:620-342-4864
Mailing Address - Fax:620-342-4937
Practice Address - Street 1:420 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5367
Practice Address - Country:US
Practice Address - Phone:620-342-4864
Practice Address - Fax:620-342-4937
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100337800AMedicaid
KS171809Medicare ID - Type UnspecifiedMEDICARE