Provider Demographics
NPI:1053358069
Name:MCCULLOUGH, MARY VERONICA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:VERONICA
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 1:1002A OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:OH
Mailing Address - Zip Code:44437-1744
Mailing Address - Country:US
Mailing Address - Phone:330-530-1958
Mailing Address - Fax:
Practice Address - Street 1:1002A OHIO AVE
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:OH
Practice Address - Zip Code:44437-1744
Practice Address - Country:US
Practice Address - Phone:330-530-1958
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2564345374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide