Provider Demographics
NPI:1548699663
Name:MACCULLOUGH, ELLEN (RN)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:MACCULLOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225 67TH DR
Mailing Address - Street 2:APT. # 4L
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2860
Mailing Address - Country:US
Mailing Address - Phone:347-886-7396
Mailing Address - Fax:
Practice Address - Street 1:10225 67TH DR
Practice Address - Street 2:APT. # 4L
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2860
Practice Address - Country:US
Practice Address - Phone:347-886-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3331171163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool