Provider Demographics
NPI:1730829078
Name:MCCULLOUGH, EMILY (FNP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:
Credentials:FNP
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 957683
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-7683
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-756-6807
Practice Address - Street 1:1103 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-756-6751
Practice Address - Fax:573-756-6807
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022008232363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner