Provider Demographics
NPI:1932083011
Name:FANN, ELIZABETH MARLO MCCULLEN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARLO MCCULLEN
Last Name:FANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARLO
Other - Last Name:MCCULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:595 HINSON RD
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-9583
Mailing Address - Country:US
Mailing Address - Phone:910-990-0410
Mailing Address - Fax:
Practice Address - Street 1:192 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7238
Practice Address - Country:US
Practice Address - Phone:910-577-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-02
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5022764363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health