Provider Demographics
NPI:1225789639
Name:MCCULLOUGH, NICOLE S
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:MCCULLOUGH
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 1:2516 WESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-3238
Mailing Address - Country:US
Mailing Address - Phone:773-553-9648
Mailing Address - Fax:
Practice Address - Street 1:2516 WESTBROOK DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-3238
Practice Address - Country:US
Practice Address - Phone:773-553-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service