Provider Demographics
NPI:1366110603
Name:MCCULLOUGH, NILE DELAWRENCE
Entity type:Individual
Prefix:
First Name:NILE
Middle Name:DELAWRENCE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 E 81ST ST APT 724
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-2221
Mailing Address - Country:US
Mailing Address - Phone:405-812-8745
Mailing Address - Fax:
Practice Address - Street 1:5320 E 81ST ST APT 724
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2221
Practice Address - Country:US
Practice Address - Phone:405-812-8745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program