Provider Demographics
NPI:1861010068
Name:MCCULLOUGH, DEIDRA (RN)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 SHULL RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1223
Mailing Address - Country:US
Mailing Address - Phone:937-516-8662
Mailing Address - Fax:
Practice Address - Street 1:200 DARUMA PKWY
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-7909
Practice Address - Country:US
Practice Address - Phone:937-963-5512
Practice Address - Fax:937-496-5274
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.303072163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse