Basic Information
| Provider Information | |||||||||
| NPI: | 1932403300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD,LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450334 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 5308 N GALLOWAY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751501125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT81969 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT81696 | 01 | TX | TX LICENSE | OTHER |