Provider Demographics
NPI:1063645166
Name:CULLEN, MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CULLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 N LAMAR BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2861
Mailing Address - Country:US
Mailing Address - Phone:662-238-7860
Mailing Address - Fax:662-238-7871
Practice Address - Street 1:1109 N LAMAR BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2861
Practice Address - Country:US
Practice Address - Phone:662-238-7860
Practice Address - Fax:662-238-7871
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03428243Medicaid
MS512I500356Medicare PIN