Provider Demographics
NPI:1982827481
Name:MCCULLOCH, SHIRLEY NEELY (APN)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:NEELY
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NORTH COUNTY SERENITY HOUSE 1341 N. ESCONDIDO BLVD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026
Mailing Address - Country:US
Mailing Address - Phone:909-549-7628
Mailing Address - Fax:
Practice Address - Street 1:NORTH COUNTY SERENITY HOUSE 1341 N. ESCONDIDO BLVD
Practice Address - Street 2:
Practice Address - City:ESCONDITO
Practice Address - State:CA
Practice Address - Zip Code:92026-5218
Practice Address - Country:US
Practice Address - Phone:844-308-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1237176B00000X
CA16801363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001516008Medicaid
NV003116008Medicaid