Provider Demographics
NPI:1912287152
Name:MCCULLOUGH, TANYA (ANP-C)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ANP-C
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 6369
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6369
Mailing Address - Country:US
Mailing Address - Phone:406-447-2823
Mailing Address - Fax:406-447-2825
Practice Address - Street 1:20 13 ST WEST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501
Practice Address - Country:US
Practice Address - Phone:406-265-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT45143163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse