Provider Demographics
NPI:1184419814
Name:MCCULLOUGH, KIA (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:KIA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97605
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27624-7605
Mailing Address - Country:US
Mailing Address - Phone:919-593-3963
Mailing Address - Fax:
Practice Address - Street 1:4924 WINDY HILL DR STE B
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4930
Practice Address - Country:US
Practice Address - Phone:919-593-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-12
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
NC337008163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No251E00000XAgenciesHome Health