Healthcare Provider Details

I. General information

NPI: 1053185694
Provider Name (Legal Business Name): MADELINE R MULDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S FAIR OAKS AVE STE 345
PASADENA CA
91105-2677
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 424-314-0203
  • Fax: 424-314-0206
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95027190
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95027190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: