Provider Demographics
NPI:1477838571
Name:MCCULLICK, CHASTITY (APRN)
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:
Last Name:MCCULLICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 N BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3016
Mailing Address - Country:US
Mailing Address - Phone:417-326-6021
Mailing Address - Fax:417-326-6347
Practice Address - Street 1:1240 N BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3016
Practice Address - Country:US
Practice Address - Phone:417-326-6021
Practice Address - Fax:417-326-6347
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO431775217363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477838571Medicaid
MO1477838571Medicaid