Provider Demographics
NPI:1497388441
Name:MCCULLOUGH, NICOLE ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELISABETH
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELISABETH
Other - Last Name:GIDDEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5296 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1165
Mailing Address - Country:US
Mailing Address - Phone:586-488-8610
Mailing Address - Fax:
Practice Address - Street 1:5296 GREENLEAF DR
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1165
Practice Address - Country:US
Practice Address - Phone:586-488-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009723363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty