Healthcare Provider Details

I. General information

NPI: 1376700799
Provider Name (Legal Business Name): MONICA HERMINE MCCULLOUGH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 E LOUISE DR STE 250
MERIDIAN ID
83642-6303
US

IV. Provider business mailing address

3405 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4399
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7312
  • Fax:
Mailing address:
  • Phone: 267-426-5421
  • Fax: 215-590-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberTP004475D
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: