Provider Demographics
NPI:1609233592
Name:MCCULLOUGH, SHANELIA
Entity Type:Individual
Prefix:
First Name:SHANELIA
Middle Name:
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 1:288 OLD MILL RD APT 43
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2086
Mailing Address - Country:US
Mailing Address - Phone:864-525-6930
Mailing Address - Fax:
Practice Address - Street 1:288 OLD MILL RD APT 43
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2086
Practice Address - Country:US
Practice Address - Phone:864-525-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC179258E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide