Provider Demographics
NPI:1649260035
Name:MCCULLOUGH, PAMELA S (NP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-786-2100
Mailing Address - Fax:540-786-6673
Practice Address - Street 1:12101 CAROL LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6101
Practice Address - Country:US
Practice Address - Phone:540-368-7835
Practice Address - Fax:540-368-7802
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024100683363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC02375OtherMEDICARE GROUP
VAP28069Medicare UPIN