MEDICARE: NICOLE S MCCULLOUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service

General Provider Information

NPI Number	:	1225789639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE S MCCULLOUGH

Provider Business Mailing Address
First Line	:	3218 LOUIS ST
Second Line	:
City	:	FRANKLIN PARK
State	:	IL
Zip	:	60131-1804
Country	:	US
Telephone Number	:	773-553-9648
Fax Number	:

Provider Business Practice Location Address
First Line	:	3218 LOUIS ST
Second Line	:
City	:	FRANKLIN PARK
State	:	IL
Zip	:	60131-1804
Country	:	US
Telephone Number	:	773-553-9648
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2022
Last Update Date	:	10/05/2025

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Directions to “ NICOLE S MCCULLOUGH ” Practice Location

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