Provider Demographics
NPI:1356593750
Name:CULLEY, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CULLEY
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 1:17415 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1119
Mailing Address - Country:US
Mailing Address - Phone:216-310-0653
Mailing Address - Fax:
Practice Address - Street 1:17415 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1119
Practice Address - Country:US
Practice Address - Phone:216-310-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173750163W00000X
OHAPRN.CNP.10383363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH173750OtherRN
OH3028673Medicaid