Healthcare Provider Details

I. General information

NPI: 1417539537
Provider Name (Legal Business Name): TERICA MCCULLOUGH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 08/21/2022
Certification Date: 08/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GOSHEN RD
RINCON GA
31326-5744
US

IV. Provider business mailing address

110 GOSHEN RD
RINCON GA
31326-5744
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-5239
  • Fax:
Mailing address:
  • Phone: 912-826-5239
  • Fax: 912-826-5237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN236530
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: