Provider Demographics
NPI:1750188850
Name:MCCULLOUGH, WANDA CERISSA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:CERISSA
Last Name:MCCULLOUGH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TUDOR AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-1327
Mailing Address - Country:US
Mailing Address - Phone:330-285-9421
Mailing Address - Fax:
Practice Address - Street 1:107 TUDOR AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-1327
Practice Address - Country:US
Practice Address - Phone:330-285-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant