Provider Demographics
NPI:1205568300
Name:MCCULLOCH, ALEXANDRIA RAENE
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:RAENE
Last Name:MCCULLOCH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 LAKE BELLEVUE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2480
Mailing Address - Country:US
Mailing Address - Phone:206-793-7168
Mailing Address - Fax:
Practice Address - Street 1:40 LAKE BELLEVUE DR STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2480
Practice Address - Country:US
Practice Address - Phone:206-793-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61370661363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health