Healthcare Provider Details

I. General information

NPI: 1699375386
Provider Name (Legal Business Name): EMILY CLOE MCCULLOCH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CLIFTON RD NE
ATLANTA GA
30322-2309
US

IV. Provider business mailing address

2381 BRADCLIFF CT NE
ATLANTA GA
30345-2611
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 404-433-6256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN254901
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN254901
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: