Provider Demographics
NPI:1851587661
Name:MCCULLOUGH, TONYA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:MARIE
Other - Last Name:MELTON, NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TONYA MARIE LACZKO
Mailing Address - Street 1:2559 AVALON ST
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-8602
Mailing Address - Country:US
Mailing Address - Phone:850-630-6371
Mailing Address - Fax:844-373-4906
Practice Address - Street 1:3107 N H ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1111
Practice Address - Country:US
Practice Address - Phone:850-630-6371
Practice Address - Fax:844-373-4906
Is Sole Proprietor?:No
Enumeration Date:2007-09-15
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2518762363L00000X
ALCRNP1-147420363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner