Provider Demographics
NPI:1790449783
Name:MCCULLEY, AMBER DENICE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DENICE
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 AFTERGLOW CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-3525
Mailing Address - Country:US
Mailing Address - Phone:901-578-5555
Mailing Address - Fax:
Practice Address - Street 1:8604 AFTERGLOW CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-3525
Practice Address - Country:US
Practice Address - Phone:901-578-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000029616251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000000029616OtherAGENCY LICENSE NUMBER