Provider Demographics
NPI:1093928442
Name:MCCULLOCH, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MCCULLOCH
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 1:2808 4TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2808 4TH ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1729
Practice Address - Country:US
Practice Address - Phone:509-594-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide