Provider Demographics
NPI:1407822968
Name:MCCULLOUGH, KATHLEEN ANN (CRNFA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2531
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-0069
Mailing Address - Country:US
Mailing Address - Phone:903-721-2274
Mailing Address - Fax:903-586-2379
Practice Address - Street 1:RR 11 BOX 923
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-9882
Practice Address - Country:US
Practice Address - Phone:903-721-2274
Practice Address - Fax:903-586-2379
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX572813163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS88344Medicare UPIN
TX83N162Medicare ID - Type Unspecified