MEDICARE: ANDREA JEAN MCCULLOUGH R.N.

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	163W00000X	Registered Nurse	R.N.143752	OH

General Provider Information

NPI Number	:	1821235391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JEAN MCCULLOUGH R.N.

Provider Business Mailing Address
First Line	:	16490 TOWNSHIP ROAD 217
Second Line	:
City	:	MOUNT VICTORY
State	:	OH
Zip	:	43340-8826
Country	:	US
Telephone Number	:	937-354-3277
Fax Number	:

Provider Business Practice Location Address
First Line	:	16490 TOWNSHIP ROAD 217
Second Line	:
City	:	MOUNT VICTORY
State	:	OH
Zip	:	43340-8826
Country	:	US
Telephone Number	:	937-354-3277
Fax Number	:

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

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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