Provider Demographics
NPI:1780680231
Name:MCCULLOUGH, REBECCA J (APN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:J
Other - Last Name:DEINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:865 LINCOLN RD
Mailing Address - Street 2:STE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4159
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:200 S CODY RD
Practice Address - Street 2:
Practice Address - City:LE CLAIRE
Practice Address - State:IA
Practice Address - Zip Code:52753-9579
Practice Address - Country:US
Practice Address - Phone:563-289-2773
Practice Address - Fax:563-289-1605
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001096363LF0000X
IAA-115743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
063228OtherHEALTH ALLIANCE
S63397Medicare UPIN