Provider Demographics
NPI:1285223206
Name:MCCULLOUGH, EBONY SHERIE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:SHERIE
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 1:3224 KALAHARI ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-3606
Mailing Address - Country:US
Mailing Address - Phone:234-410-2074
Mailing Address - Fax:
Practice Address - Street 1:3224 KALAHARI ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-3606
Practice Address - Country:US
Practice Address - Phone:234-410-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
ENGLISHOtherENGLISH
OH12345Medicaid
2345OtherENGLISH