Provider Demographics
NPI:1912684036
Name:MCCULLEY, LOGAN WAYNE (NP)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:WAYNE
Last Name:MCCULLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1089
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:985-892-7017
Practice Address - Street 1:1458 W POPLAR AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0631
Practice Address - Country:US
Practice Address - Phone:901-472-2935
Practice Address - Fax:901-432-2439
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN238135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily