Provider Demographics
NPI:1487795613
Name:MCCULLOH, LAUREL CARRIE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:CARRIE
Last Name:MCCULLOH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:LAUREL
Other - Middle Name:HAZLEWOOD
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1515 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-3530
Mailing Address - Country:US
Mailing Address - Phone:580-220-6360
Mailing Address - Fax:580-220-6708
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:580-220-6360
Practice Address - Fax:580-220-6708
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0061952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily