MEDICARE: MISS DARLENE MCCULLOUGH NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	159554	GA

General Provider Information

NPI Number	:	1528570504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DARLENE MCCULLOUGH NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	3770 OLD OAK CT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2386
Country	:	US
Telephone Number	:	404-432-2873
Fax Number	:

Provider Business Practice Location Address
First Line	:	2575 JOLLY RD
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-3165
Country	:	US
Telephone Number	:	404-767-8886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2017
Last Update Date	:	10/30/2017

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