Provider Demographics
NPI:1013618743
Name:MCCULLOUGH, COLLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2950 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2228
Practice Address - Country:US
Practice Address - Phone:510-535-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2023168702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily