Provider Demographics
NPI:1376776591
Name:MCCULLOCH, YELENA (LMP)
Entity Type:Individual
Prefix:MRS
First Name:YELENA
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12104 N DENVER DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1789
Mailing Address - Country:US
Mailing Address - Phone:509-863-9909
Mailing Address - Fax:
Practice Address - Street 1:12104 N DENVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1789
Practice Address - Country:US
Practice Address - Phone:509-863-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60058182172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker