Provider Demographics
NPI:1760284483
Name:MCCULLOM, LAMONICE MARIE (NP)
Entity type:Individual
Prefix:
First Name:LAMONICE
Middle Name:MARIE
Last Name:MCCULLOM
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4279
Mailing Address - Country:US
Mailing Address - Phone:228-224-7953
Mailing Address - Fax:
Practice Address - Street 1:451 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2507
Practice Address - Country:US
Practice Address - Phone:228-400-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907308363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner