Provider Demographics
NPI:1285627273
Name:MCCULLOUGH, KELLY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 LAND O LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-2826
Mailing Address - Country:US
Mailing Address - Phone:727-774-2360
Mailing Address - Fax:813-794-2120
Practice Address - Street 1:7227 LAND O LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-2826
Practice Address - Country:US
Practice Address - Phone:727-774-2360
Practice Address - Fax:813-794-2120
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2752232363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner