Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 2203014405 | UT |
NPI | 1275672396 |
---|---|
Provider Name | Mary Elizabeth Mcculloch |
First Address | Park City, UT 84098-8507 |
Second Address | Slc, UT 84132-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 08/07/2007 |