Provider Demographics
NPI:1235517749
Name:MCCULLOCH, NATALIE AVA (ARNP)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:AVA
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:AVA
Other - Last Name:SORENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-534-7000
Mailing Address - Fax:253-530-2675
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-534-7000
Practice Address - Fax:253-530-2675
Is Sole Proprietor?:No
Enumeration Date:2015-05-16
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60593750363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047769Medicaid