Provider Demographics
NPI:1629064563
Name:MCCULLOUGH, DEBRA LYNNE (ADVCD PRACTICE NURSE)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNNE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ADVCD PRACTICE NURSE
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:LYNNE
Other - Last Name:RUSK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-6308
Mailing Address - Country:US
Mailing Address - Phone:432-524-1434
Mailing Address - Fax:432-524-1461
Practice Address - Street 1:208 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:TX
Practice Address - Zip Code:79714-6308
Practice Address - Country:US
Practice Address - Phone:432-524-1434
Practice Address - Fax:432-524-1461
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX503337363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner