Basic Information
Provider Information | |||||||||
NPI: | 1780680231 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCULLOUGH | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEINES | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 865 LINCOLN RD | ||||||||
Address2: | STE L10 | ||||||||
City: | BETTENDORF | ||||||||
State: | IA | ||||||||
PostalCode: | 527224159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5633559191 | ||||||||
FaxNumber: | 5633553419 | ||||||||
Practice Location | |||||||||
Address1: | 200 S CODY RD | ||||||||
Address2: |   | ||||||||
City: | LE CLAIRE | ||||||||
State: | IA | ||||||||
PostalCode: | 527539579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5632892773 | ||||||||
FaxNumber: | 5632891605 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2005 | ||||||||
LastUpdateDate: | 08/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209001096 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A-115743 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 063228 | 01 |   | HEALTH ALLIANCE | OTHER |