Provider Demographics
NPI:1508462391
Name:MCCULLEY, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:MCCULLEY
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 1:5344 TRAILVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4645
Mailing Address - Country:US
Mailing Address - Phone:314-309-7758
Mailing Address - Fax:
Practice Address - Street 1:5344 TRAILVIEW DR
Practice Address - Street 2:
Practice Address - City:BLACK JACK
Practice Address - State:MO
Practice Address - Zip Code:63033-4645
Practice Address - Country:US
Practice Address - Phone:314-309-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16982862Medicaid