Provider Demographics
NPI:1861657280
Name:MCCULLOUGH, LISA RAE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:4722 N 24TH ST
Mailing Address - Street 2:STE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4800
Mailing Address - Country:US
Mailing Address - Phone:877-737-4546
Mailing Address - Fax:602-957-9438
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-447-8812
Practice Address - Fax:719-447-8987
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO5336363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal