Healthcare Provider Details

I. General information

NPI: 1114390465
Provider Name (Legal Business Name): HEIDI LEANN MCCULLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W SIERRA MADRE BLVD STE 200
SIERRA MADRE CA
91024-2467
US

IV. Provider business mailing address

1260 REXFORD AVE
PASADENA CA
91107-1614
US

V. Phone/Fax

Practice location:
  • Phone: 626-708-3391
  • Fax: 626-351-1682
Mailing address:
  • Phone: 626-708-8384
  • Fax: 626-351-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: