Healthcare Provider Details

I. General information

NPI: 1124245592
Provider Name (Legal Business Name): PEGGY LOU MULLIGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

130 WINDERMERE DR
YONKERS NY
10710-2408
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2313
  • Fax:
Mailing address:
  • Phone: 914-793-8845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF333051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: