Provider Demographics
NPI:1609331016
Name:MCCULLOUGH, ANNA LOIS (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:LOIS
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:LOIS
Other - Last Name:CROWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:706 N WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2620
Mailing Address - Country:US
Mailing Address - Phone:765-409-8621
Mailing Address - Fax:
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2690
Practice Address - Country:US
Practice Address - Phone:765-660-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN693011133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered