Provider Demographics
NPI:1922290147
Name:MCCULLOUGH, PAMELA (RD, LD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 REGALVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-4154
Mailing Address - Country:US
Mailing Address - Phone:469-230-6230
Mailing Address - Fax:
Practice Address - Street 1:7051 REGALVIEW CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4154
Practice Address - Country:US
Practice Address - Phone:469-230-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-11
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered