Provider Demographics
NPI:1700806262
Name:MCCULLOUGH, COLLETTE SMITH (ARNP)
Entity Type:Individual
Prefix:
First Name:COLLETTE
Middle Name:SMITH
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1317
Mailing Address - Country:US
Mailing Address - Phone:712-202-0777
Mailing Address - Fax:
Practice Address - Street 1:800 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1317
Practice Address - Country:US
Practice Address - Phone:712-202-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA053998163W00000X
IAZ-053998363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA053998OtherRN LICENSE
IAZ-053998OtherARNP-CNS LICENSES