Provider Demographics
NPI:1780915256
Name:CULLEN, MARY ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CULLEN
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 1:9471 WHISPERING TRCE
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9208
Mailing Address - Country:US
Mailing Address - Phone:317-752-6795
Mailing Address - Fax:
Practice Address - Street 1:9471 WHISPERING TRCE
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-9208
Practice Address - Country:US
Practice Address - Phone:317-752-6795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-24
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001424A133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN796270TTMedicare PIN