=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316191745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORNELIA M. MCCULLOUGH ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2008
-----------------------------------------------------
Last Update Date | 05/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1255 LILA ST UFJAX - LEM TURNER FAMILY MEDICINE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32208-3550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-383-1001
-----------------------------------------------------
Fax | 904-244-5791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 44008 UFJP - PROVIDER ENROLLMENT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32231-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-3199
-----------------------------------------------------
Fax | 904-244-3425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | ARNP3228512
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------