Provider Demographics
NPI:1336506690
Name:CULLEN, HEATHER LEIGH
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:CULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 MCELHANEY RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1734
Practice Address - Country:US
Practice Address - Phone:864-834-3192
Practice Address - Fax:864-241-9234
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004566RX363A00000X
SC3198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant