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NPI Code Detail

MEDICARE: ELIZABETH MARLO MCCULLEN FANN

MEDICARE: ELIZABETH MARLO MCCULLEN FANN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner5022764NC

General Provider Information

NPI Number : 1932083011
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZABETH MARLO MCCULLEN FANN
Provider Business Mailing Address
First Line : 595 HINSON RD
Second Line :
City : DUNN
State : NC
Zip : 28334-9583
Country : US
Telephone Number : 910-990-0410
Fax Number :
Provider Business Practice Location Address
First Line : 192 VILLAGE DR
Second Line :
City : JACKSONVILLE
State : NC
Zip : 28546-7238
Country : US
Telephone Number : 910-577-1400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2025
Last Update Date : 08/08/2025

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