Provider Demographics
NPI:1043965510
Name:KILCULLEN, IRENE
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:KILCULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 HAZELRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-6542
Mailing Address - Country:US
Mailing Address - Phone:818-261-8416
Mailing Address - Fax:
Practice Address - Street 1:5412 BOULDER HWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6039
Practice Address - Country:US
Practice Address - Phone:702-291-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty