Healthcare Provider Details

I. General information

NPI: 1902248891
Provider Name (Legal Business Name): ANITA CAROL COLLINS -MCCULLUM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 MEDICAL PLAZA LN
WHITESBURG KY
41858
US

IV. Provider business mailing address

PO BOX 40
WHITESBURG KY
41858-0040
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-4871
  • Fax:
Mailing address:
  • Phone: 606-633-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21682
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3008262
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: