MEDICARE: SHAVON MC CULLOUGH

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1417757105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAVON MC CULLOUGH

Provider Business Mailing Address
First Line	:	320 N 36TH ST UNIT 124
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68503-3364
Country	:	US
Telephone Number	:	531-220-2165
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 N 36TH ST UNIT 124
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68503-3364
Country	:	US
Telephone Number	:	531-220-2165
Fax Number	:

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

Provider Enumeration Date	:	03/13/2025
Last Update Date	:	03/13/2025

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Directions to “ SHAVON MC CULLOUGH ” Practice Location

Language	Start Address	Practice Location

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