1558570390 NPI number — HEATHER MCMULLEN

Table of content: HEATHER MCMULLEN (NPI 1558570390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558570390 NPI number — HEATHER MCMULLEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMULLEN
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558570390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 93
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95461-0093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-701-3331
Provider Business Mailing Address Fax Number:
707-701-3331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9667 HWY 29
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOWER LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-701-3331
Provider Business Practice Location Address Fax Number:
707-881-5505
Provider Enumeration Date:
05/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  24227 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)