Provider Demographics
NPI:1114390465
Name:MCCULLY, HEIDI LEANN
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEANN
Last Name:MCCULLY
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 1:1260 REXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1614
Mailing Address - Country:US
Mailing Address - Phone:626-708-8384
Mailing Address - Fax:626-351-1682
Practice Address - Street 1:55 W SIERRA MADRE BLVD
Practice Address - Street 2:STE 200
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2467
Practice Address - Country:US
Practice Address - Phone:626-708-3391
Practice Address - Fax:626-351-1682
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA450176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife