Provider Demographics
NPI:1700882487
Name:MCCULLOUGH, CATHY LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:LYNN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:KNIGHTS AND RED LION ROADS
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-0000
Mailing Address - Country:US
Mailing Address - Phone:215-491-7496
Mailing Address - Fax:
Practice Address - Street 1:KNIGHTS AND RED LIONS ROADS
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN240162L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007223Medicare ID - Type Unspecified