Basic Information
| Provider Information | |||||||||
| NPI: | 1205452141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | KATHRYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Practice Location | |||||||||
| Address1: | 2454 HWY 6 AND 50 STE 104 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815051117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706449900 | ||||||||
| FaxNumber: | 9707735937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0995228-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.