Healthcare Provider Details

I. General information

NPI: 1386976835
Provider Name (Legal Business Name): LEIA JUNE MCCULLOUGH RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BONNIE LN
SYLVA NC
28779-8511
US

IV. Provider business mailing address

PO BOX 2187
SYLVA NC
28779-2187
US

V. Phone/Fax

Practice location:
  • Phone: 828-631-3973
  • Fax: 828-631-9280
Mailing address:
  • Phone: 828-631-3973
  • Fax: 828-631-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5011033
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number219356
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: