Provider Demographics
NPI:1609058494
Name:MCCULLEN, DAWN
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:MCCULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6017
Mailing Address - Country:US
Mailing Address - Phone:910-265-1756
Mailing Address - Fax:910-938-0045
Practice Address - Street 1:113 COURTLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6017
Practice Address - Country:US
Practice Address - Phone:910-265-1756
Practice Address - Fax:910-938-0045
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408969Medicaid