Provider Demographics
NPI:1386962983
Name:MCCULLOUGH-WILLS, TRACY L (RD)
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:L
Last Name:MCCULLOUGH-WILLS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 ELLIS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-4431
Mailing Address - Country:US
Mailing Address - Phone:609-760-8950
Mailing Address - Fax:856-417-3432
Practice Address - Street 1:1339 ELLIS MILL RD
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-4431
Practice Address - Country:US
Practice Address - Phone:609-760-8950
Practice Address - Fax:856-417-3432
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA804997133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered