Provider Demographics
NPI:1205452141
Name:MCCULLOUGH, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4273
Mailing Address - Country:US
Mailing Address - Phone:970-249-7751
Mailing Address - Fax:970-249-5029
Practice Address - Street 1:2454 HWY 6 AND 50 STE 104
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1117
Practice Address - Country:US
Practice Address - Phone:970-644-9900
Practice Address - Fax:970-773-5937
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0995228-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner