Provider Demographics
NPI:1962754531
Name:MCCULLOUGH, EDWARD F (ARNP)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:F
Last Name:MCCULLOUGH
Suffix:
Gender:M
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:PO BOX 47247
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-7247
Mailing Address - Country:US
Mailing Address - Phone:727-564-1441
Mailing Address - Fax:
Practice Address - Street 1:2852 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3127
Practice Address - Country:US
Practice Address - Phone:727-564-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9266748363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner