Healthcare Provider Details

I. General information

NPI: 1477249894
Provider Name (Legal Business Name): NICOLE LYNNETTE MULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10631 TIERRASANTA BLVD
SAN DIEGO CA
92124-2605
US

IV. Provider business mailing address

10416 EL NOPAL
SANTEE CA
92071-4907
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-0972
  • Fax: 858-576-0035
Mailing address:
  • Phone: 619-954-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number183536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: