Provider Demographics
NPI:1235628645
Name:MCCULLUM, LAVENA (APRN)
Entity Type:Individual
Prefix:
First Name:LAVENA
Middle Name:
Last Name:MCCULLUM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LAVENA
Other - Middle Name:MARIE
Other - Last Name:HAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4166 WYNTREE DR STE B
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2521
Mailing Address - Country:US
Mailing Address - Phone:502-889-9677
Mailing Address - Fax:
Practice Address - Street 1:4166 WYNTREE DR STE B
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2521
Practice Address - Country:US
Practice Address - Phone:502-889-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007953A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health