Healthcare Provider Details

I. General information

NPI: 1407895667
Provider Name (Legal Business Name): SUSAN CAROL MCMULLEN N.P.02/07/1966
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 PINE AVE EXTENDED CARE SNF
TRUCKEE CA
96161-4856
US

IV. Provider business mailing address

10956 DONNER PASS RD #230
TRUCKEE CA
96161-4861
US

V. Phone/Fax

Practice location:
  • Phone: 530-582-3251
  • Fax: 530-582-3281
Mailing address:
  • Phone: 530-582-3277
  • Fax: 530-550-0544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: