Healthcare Provider Details

I. General information

NPI: 1366535890
Provider Name (Legal Business Name): ANDREA MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 S MAIN ST
WILLITS CA
95490-4394
US

IV. Provider business mailing address

1245 S MAIN ST
WILLITS CA
95490-4305
US

V. Phone/Fax

Practice location:
  • Phone: 707-459-6861
  • Fax:
Mailing address:
  • Phone: 707-459-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA61951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: