Healthcare Provider Details

I. General information

NPI: 1487018206
Provider Name (Legal Business Name): KELLY VERONICA MULLEN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PULASKI RD
KINGS PARK NY
11754-2539
US

IV. Provider business mailing address

39 SOUNDVIEW DR
NORTHPORT NY
11768-1446
US

V. Phone/Fax

Practice location:
  • Phone: 631-678-8470
  • Fax:
Mailing address:
  • Phone: 631-678-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306187
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number306187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: