Provider Demographics
NPI:1659673127
Name:MCCULLOUGH BANKSTON, KELLY R (RN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:MCCULLOUGH BANKSTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23585 CANNON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1631
Mailing Address - Country:US
Mailing Address - Phone:216-551-1293
Mailing Address - Fax:
Practice Address - Street 1:23585 CANNON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD HTS
Practice Address - State:OH
Practice Address - Zip Code:44146-1631
Practice Address - Country:US
Practice Address - Phone:216-551-1293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH366051163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse