Provider Demographics
NPI:1881159713
Name:MCCULLOUGH, KATRINA (TRANSPORTATION)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:TRANSPORTATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-1941
Mailing Address - Country:US
Mailing Address - Phone:785-819-6660
Mailing Address - Fax:785-833-2291
Practice Address - Street 1:503 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-1941
Practice Address - Country:US
Practice Address - Phone:785-819-6660
Practice Address - Fax:785-833-2291
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK02176486172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS833421497OtherIRS
KS83-3421497OtherIRS