Basic Information
| Provider Information | |||||||||
| NPI: | 1558368910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LUCILLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMBOGI | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | LUCILLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2298 SPRINGPORT RD | ||||||||
| Address2: | STE B | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492021475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177843950 | ||||||||
| FaxNumber: | 5178171681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 SPRINGPORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492021432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177849356 | ||||||||
| FaxNumber: | 5177809286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 4704201104 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.