Provider Demographics
NPI:1841669421
Name:CULLOM, GINA (RN)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CULLOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 GLEASON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5243
Mailing Address - Country:US
Mailing Address - Phone:937-232-8720
Mailing Address - Fax:
Practice Address - Street 1:3040 KEMP RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2644
Practice Address - Country:US
Practice Address - Phone:937-458-2315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH322609163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool