Provider Demographics
NPI:1114530342
Name:MCCAULLEY, ANDREW BLAKE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:BLAKE
Last Name:MCCAULLEY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852
Mailing Address - Country:US
Mailing Address - Phone:662-423-1000
Mailing Address - Fax:
Practice Address - Street 1:1507 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1133
Practice Address - Country:US
Practice Address - Phone:662-423-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily