Provider Demographics
NPI:1558139683
Name:MCCULLOUGH, LAUREN DOREEN (FNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:DOREEN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 SLATE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1887
Mailing Address - Country:US
Mailing Address - Phone:416-301-5702
Mailing Address - Fax:
Practice Address - Street 1:178 SLATE LN
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1887
Practice Address - Country:US
Practice Address - Phone:416-301-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily