Provider Demographics
NPI:1265574370
Name:MCCULLOUGH, BRENDA SUE (FNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
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 1:107 W 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-2809
Mailing Address - Country:US
Mailing Address - Phone:806-688-4205
Mailing Address - Fax:806-688-4211
Practice Address - Street 1:107 W 30TH AVE
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2809
Practice Address - Country:US
Practice Address - Phone:806-688-4205
Practice Address - Fax:806-688-4211
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX534073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB117082Medicare PIN