Healthcare Provider Details

I. General information

NPI: 1558636332
Provider Name (Legal Business Name): TINA L MCCULLOUGH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CLARK ST
CAMBRIDGE OH
43725-9614
US

IV. Provider business mailing address

859 N MAIN ST
MALTA OH
43758-9007
US

V. Phone/Fax

Practice location:
  • Phone: 740-421-9530
  • Fax: 740-421-9531
Mailing address:
  • Phone: 740-962-6111
  • Fax: 740-962-2182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.12918-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: