Healthcare Provider Details

I. General information

NPI: 1629775499
Provider Name (Legal Business Name): SHIR'MEL CANDIS MCCULLOUGH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 GERVAIS ST
COLUMBIA SC
29204-1805
US

IV. Provider business mailing address

PO BOX 3788
COLUMBIA SC
29230-3788
US

V. Phone/Fax

Practice location:
  • Phone: 803-744-0540
  • Fax: 803-744-0542
Mailing address:
  • Phone: 803-733-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28094
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: