Provider Demographics
NPI:1841345915
Name:MCCULLY, MILDRED FLEMING (CPNP)
Entity type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:FLEMING
Last Name:MCCULLY
Suffix:
Gender:F
Credentials:CPNP
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 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-6000
Mailing Address - Fax:
Practice Address - Street 1:103 STUARD ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-1263
Practice Address - Country:US
Practice Address - Phone:864-514-1080
Practice Address - Fax:864-560-1090
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300071363LP0200X
SC19766363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCC6125019OtherMEDICARE PIN
SCSCC6123365OtherMEDICARE PIN
SCNP3570Medicaid
SCSCC612J577OtherMEDICARE PIN
SCSCC612H895OtherMEDICARE PIN