Provider Demographics
NPI:1316405905
Name:MCCULLOCH, ANDREA MARIE (MSN, RN, AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MSN, RN, AGACNP-BC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 W HARGETT ST APT 728
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-4082
Mailing Address - Country:US
Mailing Address - Phone:734-740-6085
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:734-740-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCALLE-FVSF53363L00000X
NC5011544363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology