Provider Demographics
NPI:1689430258
Name:MCCULLOUGH, KIMBERLY MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 PENNANT AVE
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08722-3933
Mailing Address - Country:US
Mailing Address - Phone:848-333-3372
Mailing Address - Fax:
Practice Address - Street 1:300 W WATER ST STE A
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-6692
Practice Address - Country:US
Practice Address - Phone:732-800-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00833200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant