Healthcare Provider Details

I. General information

NPI: 1609058494
Provider Name (Legal Business Name): DAWN MCCULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 COURTLAND DR
JACKSONVILLE NC
28546-6017
US

IV. Provider business mailing address

113 COURTLAND DR
JACKSONVILLE NC
28546-6017
US

V. Phone/Fax

Practice location:
  • Phone: 910-265-1756
  • Fax: 910-938-0045
Mailing address:
  • Phone: 910-265-1756
  • Fax: 910-938-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: