Provider Demographics
NPI:1407517121
Name:MCCOLLOUGH, MARKETTA
Entity Type:Individual
Prefix:
First Name:MARKETTA
Middle Name:
Last Name:MCCOLLOUGH
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 1:500 PARK AVE APT 627
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5034
Mailing Address - Country:US
Mailing Address - Phone:773-656-7427
Mailing Address - Fax:
Practice Address - Street 1:9932 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1831
Practice Address - Country:US
Practice Address - Phone:312-868-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2023-N1952163WC1500X, 163WR0400X, 163WH0200X, 163W00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
No172V00000XOther Service ProvidersCommunity Health Worker
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse