Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | 303362 | NY |
NPI | 1457705956 |
---|---|
Provider Name | Stephanie Renae Jackson Cullison |
First Address | Philadelphia, PA 19107-4408 |
Second Address | Wilmington, DE 19810-4900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2016 |
Last Update Date | 16/08/2021 |