Provider Demographics
NPI:1417436676
Name:MCCULLOUGH, BETHANIE LYNN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:BETHANIE
Middle Name:LYNN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1721
Mailing Address - Country:US
Mailing Address - Phone:401-575-7754
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE STE 775
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1838
Practice Address - Country:US
Practice Address - Phone:517-364-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704284537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447344502OtherINDIVIDUAL