Provider Demographics
NPI:1265892608
Name:CULLY, LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:CULLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1758
Mailing Address - Country:US
Mailing Address - Phone:703-391-0111
Mailing Address - Fax:
Practice Address - Street 1:3620 JOSEPH SIEWICK DR STE 201
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1758
Practice Address - Country:US
Practice Address - Phone:703-391-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant