Healthcare Provider Details

I. General information

NPI: 1841149796
Provider Name (Legal Business Name): BROOKE LYN MCCULLEY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
GIDEON MO
63848-9253
US

IV. Provider business mailing address

100 N MAIN ST
GIDEON MO
63848-9253
US

V. Phone/Fax

Practice location:
  • Phone: 573-448-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4016429
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2026005075
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: