Healthcare Provider Details

I. General information

NPI: 1609500404
Provider Name (Legal Business Name): HEATHER ROSE MCMULLAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

1490 CENTRE ST
NEWTON MA
02459-2447
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone: 617-953-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN267413
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN267413
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: