Provider Demographics
NPI:1881235471
Name:MCCULLEY, CATHERINE MICHELLE (CNP)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:MICHELLE
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:CATHERINE
Other - Middle Name:MICHELLE
Other - Last Name:TIBBETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:115 N DAKOTA AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6425
Mailing Address - Country:US
Mailing Address - Phone:605-370-0993
Mailing Address - Fax:
Practice Address - Street 1:6709 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2592
Practice Address - Country:US
Practice Address - Phone:605-271-2700
Practice Address - Fax:605-271-2277
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001647363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily