Provider Demographics
NPI:1124494174
Name:MCCULLEY, MARY LOU (RN CDE)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOU
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:RN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-842-2611
Mailing Address - Fax:618-847-8388
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1203
Practice Address - Country:US
Practice Address - Phone:618-842-2611
Practice Address - Fax:618-847-8388
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041359796174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator