Provider Demographics
NPI:1407096068
Name:WILLIS-MCCULLOUGH, MARTINA TAMARA (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARTINA
Middle Name:TAMARA
Last Name:WILLIS-MCCULLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 7TH AVE S
Mailing Address - Street 2:ACC BLDG SUITE 422
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1711
Mailing Address - Country:US
Mailing Address - Phone:205-939-5900
Mailing Address - Fax:205-939-5920
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:ACC BLDG SUITE 422
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-5900
Practice Address - Fax:205-939-5920
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106592163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation