Provider Demographics
NPI:1467234187
Name:MCCULLOUGH-GRACIA, KYLI ANN (FNP- BC, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KYLI
Middle Name:ANN
Last Name:MCCULLOUGH-GRACIA
Suffix:
Gender:F
Credentials:FNP- BC, FNP-C
Other - Prefix:MISS
Other - First Name:KYLI
Other - Middle Name:ANN
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD, RN
Mailing Address - Street 1:610 N SAWYER RD
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-2566
Mailing Address - Country:US
Mailing Address - Phone:260-347-5592
Mailing Address - Fax:
Practice Address - Street 1:610 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2566
Practice Address - Country:US
Practice Address - Phone:260-347-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0034654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily