Provider Demographics
NPI:1508106709
Name:MCCULLOUGH, KATHLEEN B (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BOX 679-B
Mailing Address - Street 2:601 ELMWOOD AVE.
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-341-6780
Mailing Address - Fax:585-341-8489
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2733
Practice Address - Country:US
Practice Address - Phone:585-341-6780
Practice Address - Fax:585-341-8489
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430654363AM0700X
NYF430654-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical