Provider Demographics
NPI:1114339314
Name:MCCULLOUGH, MARQUITA MONIQUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARQUITA
Middle Name:MONIQUE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17730 WAKENDEN
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2269
Mailing Address - Country:US
Mailing Address - Phone:313-703-5015
Mailing Address - Fax:
Practice Address - Street 1:24424 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3653
Practice Address - Country:US
Practice Address - Phone:313-531-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111212164W00000X
MI4704340478163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse