Healthcare Provider Details

I. General information

NPI: 1013618743
Provider Name (Legal Business Name): COLLEEN MCCULLOUGH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/03/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 INTERNATIONAL BLVD
OAKLAND CA
94601-2228
US

IV. Provider business mailing address

7 VALLEY VIEW RD
ORINDA CA
94563-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023168702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: