Provider Demographics
NPI:1619487345
Name:CULLINAN, MICHELLE THERESE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESE
Last Name:CULLINAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:THERESE
Other - Last Name:VIOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:413 N ALLUMBAUGH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9219
Mailing Address - Country:US
Mailing Address - Phone:208-323-1125
Mailing Address - Fax:
Practice Address - Street 1:413 N ALLUMBAUGH ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9219
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57455363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program