Provider Demographics
NPI:1093409369
Name:MCCULLOUGH-LEE, LUDELLA
Entity Type:Individual
Prefix:
First Name:LUDELLA
Middle Name:
Last Name:MCCULLOUGH-LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2103
Mailing Address - Country:US
Mailing Address - Phone:662-318-5018
Mailing Address - Fax:
Practice Address - Street 1:358 E JAVELINA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6205
Practice Address - Country:US
Practice Address - Phone:480-507-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906019363LP0808X
AZ300564363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health