=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760284483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAMONICE MARIE MCCULLOM NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2025
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 HIGHWAY 90
-----------------------------------------------------
City | WAVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39576-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-400-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10580 STEEPLECHASE DR
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-224-7953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 907308
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------