MEDICARE: STEPHANIE MULLEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	317893	NY

General Provider Information

NPI Number	:	1003450503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MULLEN

Provider Business Mailing Address
First Line	:	2172 COLLEGE AVE
Second Line	:
City	:	ELMIRA HEIGHTS
State	:	NY
Zip	:	14903-1287
Country	:	US
Telephone Number	:	160-748-3259
Fax Number	:

Provider Business Practice Location Address
First Line	:	2172 COLLEGE AVE
Second Line	:
City	:	ELMIRA HEIGHTS
State	:	NY
Zip	:	14903-1287
Country	:	US
Telephone Number	:	160-748-3259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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Directions to “ STEPHANIE MULLEN ” Practice Location

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