Healthcare Provider Details

I. General information

NPI: 1255587382
Provider Name (Legal Business Name): PETER NATHAN MCMULLEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

IV. Provider business mailing address

114 LEVESQUE AVE
WEST HARTFORD CT
06110-1180
US

V. Phone/Fax

Practice location:
  • Phone: 860-667-6733
  • Fax: 860-667-6842
Mailing address:
  • Phone: 860-232-0592
  • Fax: 860-232-0592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberE-38767
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: