Healthcare Provider Details

I. General information

NPI: 1184419814
Provider Name (Legal Business Name): KIA MCCULLOUGH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2025
Last Update Date: 04/12/2025
Certification Date: 04/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 WINDY HILL DR STE B
RALEIGH NC
27609-4930
US

IV. Provider business mailing address

PO BOX 97605
RALEIGH NC
27624-7605
US

V. Phone/Fax

Practice location:
  • Phone: 919-593-3963
  • Fax:
Mailing address:
  • Phone: 919-593-3963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number337008
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: