Healthcare Provider Details

I. General information

NPI: 1629687553
Provider Name (Legal Business Name): EDNA ROTHMAN MULLALLY DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 N CROATAN HWY
KITTY HAWK NC
27949-3990
US

IV. Provider business mailing address

PO BOX 2287
KITTY HAWK NC
27949-2287
US

V. Phone/Fax

Practice location:
  • Phone: 252-261-4187
  • Fax: 833-989-2346
Mailing address:
  • Phone: 252-261-4187
  • Fax: 833-989-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5017152
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: