Provider Demographics
NPI:1336129303
Name:SCULLY, CATHLEEN A (NP)
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:A
Last Name:SCULLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2160 FOUNTAIN DR
Mailing Address - Street 2:SOUTHEASTERN GERIATRIC HEALTHCARE GROUP
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2914
Mailing Address - Country:US
Mailing Address - Phone:770-982-2336
Mailing Address - Fax:770-972-0805
Practice Address - Street 1:2160 FOUNTAIN DR
Practice Address - Street 2:SOUTHEASTERN GERIATRIC HEALTHCARE GROUP
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2914
Practice Address - Country:US
Practice Address - Phone:770-982-2336
Practice Address - Fax:770-972-0805
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN152213363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBGQCMedicare ID - Type Unspecified
GAP66650Medicare UPIN