Healthcare Provider Details

I. General information

NPI: 1992542286
Provider Name (Legal Business Name): MICHAEL CUELLAR FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MARGIE DR
WARNER ROBINS GA
31088-7818
US

IV. Provider business mailing address

3708 NORTHSIDE DR
MACON GA
31210-2404
US

V. Phone/Fax

Practice location:
  • Phone: 478-971-1153
  • Fax:
Mailing address:
  • Phone: 478-745-4206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN204647
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: