Healthcare Provider Details

I. General information

NPI: 1245076553
Provider Name (Legal Business Name): JEREMY MULLAVEY ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/05/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 W 7TH AVE STE 110
SPOKANE WA
99204-2321
US

IV. Provider business mailing address

4308 E 41ST AVE
SPOKANE WA
99223-1279
US

V. Phone/Fax

Practice location:
  • Phone: 509-456-0262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAP61577243
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberAP61577243
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: