Provider Demographics
NPI:1558368910
Name:MCCULLY, LAURA LUCILLE (CNM)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:LUCILLE
Last Name:MCCULLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LUCILLE
Other - Last Name:GAMBOGI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2298 SPRINGPORT RD
Mailing Address - Street 2:STE B
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1475
Mailing Address - Country:US
Mailing Address - Phone:517-784-3950
Mailing Address - Fax:517-817-1681
Practice Address - Street 1:2200 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1432
Practice Address - Country:US
Practice Address - Phone:517-784-9356
Practice Address - Fax:517-780-9286
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201104367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ33274Medicare UPIN
MIPO9890001Medicare ID - Type UnspecifiedMEDICARE PART B #