Basic Information
| Provider Information | |||||||||
| NPI: | 1558636332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 859 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MALTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437589007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409626111 | ||||||||
| FaxNumber: | 7409622182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437259614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404219530 | ||||||||
| FaxNumber: | 7404219531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.12918-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0062479 | 05 | OH | MEDICAID |