Provider Demographics
NPI:1679262406
Name:KULLMAN, PATRICIA L
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:KULLMAN
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 1:162 BROOKSHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9708
Mailing Address - Country:US
Mailing Address - Phone:419-750-4148
Mailing Address - Fax:
Practice Address - Street 1:162 BROOKSHORE DR
Practice Address - Street 2:
Practice Address - City:CHIPPEWA LAKE
Practice Address - State:OH
Practice Address - Zip Code:44215-9708
Practice Address - Country:US
Practice Address - Phone:419-750-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRQ251483172A00000X
174200000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No172A00000XOther Service ProvidersDriver
No174200000XOther Service ProvidersMeals