Provider Demographics
NPI:1043276546
Name:MCCULLOCH, BRANDY D (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:D
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4283
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36803-4283
Mailing Address - Country:US
Mailing Address - Phone:334-528-1112
Mailing Address - Fax:334-528-1547
Practice Address - Street 1:2000 PEPPERELL PKWY
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5452
Practice Address - Country:US
Practice Address - Phone:334-528-1112
Practice Address - Fax:334-528-1547
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-080202363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-31508OtherBLUE CROSS OF AL PROV #
AL559400210OtherALABAMA MEDICAID GROUP #
AL891010412Medicaid
AL051556854YATMedicare ID - Type UnspecifiedPROVIDER #
AL559400210OtherALABAMA MEDICAID GROUP #