Healthcare Provider Details

I. General information

NPI: 1366868598
Provider Name (Legal Business Name): NYSHAE CULLY DUCKETT PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 ARLINGTON AVE SUITE B
RIVERSIDE CA
92504-2738
US

IV. Provider business mailing address

PO BOX 5109
RIVERSIDE CA
92517-5109
US

V. Phone/Fax

Practice location:
  • Phone: 951-341-8930
  • Fax: 951-341-8932
Mailing address:
  • Phone: 951-341-8930
  • Fax: 951-341-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95004355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: