Provider Demographics
NPI:1013378553
Name:MCCULLOUGH, DOMINISE (RN)
Entity Type:Individual
Prefix:
First Name:DOMINISE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 OLD CAMDEN SQ
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-7954
Mailing Address - Country:US
Mailing Address - Phone:608-514-5697
Mailing Address - Fax:
Practice Address - Street 1:2718 OLD CAMDEN SQ
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-7954
Practice Address - Country:US
Practice Address - Phone:608-514-5697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315839-31164W00000X
WI247508-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse