Basic Information
| Provider Information | |||||||||
| NPI: | 1417539537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | TERICA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 GOSHEN RD | ||||||||
| Address2: | |||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313265744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128265239 | ||||||||
| FaxNumber: | 9128265237 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 GOSHEN RD | ||||||||
| Address2: | |||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313265744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128265239 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2021 | ||||||||
| LastUpdateDate: | 08/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN236530 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.