Provider Demographics
NPI:1124842463
Name:MCCULLOUGH, SANDRA JEANNE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEANNE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JEANNE
Other - Last Name:BROWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:591 S DESERT HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2811
Mailing Address - Country:US
Mailing Address - Phone:334-362-3476
Mailing Address - Fax:
Practice Address - Street 1:150 W AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6035
Practice Address - Country:US
Practice Address - Phone:520-225-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX756806163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool