Healthcare Provider Details

I. General information

NPI: 1669858890
Provider Name (Legal Business Name): MARY MCMULLEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY MARGARET HEGERTY

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0000
  • Fax:
Mailing address:
  • Phone: 317-554-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28080466A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71005847A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: