MEDICARE: NICOLE LYNNETTE 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	183700000X	Pharmacy Technician	183536	CA

General Provider Information

NPI Number	:	1477249894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LYNNETTE MULLEN

Provider Business Mailing Address
First Line	:	10416 EL NOPAL
Second Line	:
City	:	SANTEE
State	:	CA
Zip	:	92071-4907
Country	:	US
Telephone Number	:	619-954-3976
Fax Number	:

Provider Business Practice Location Address
First Line	:	10631 TIERRASANTA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-2605
Country	:	US
Telephone Number	:	858-576-0972
Fax Number	:	858-576-0035

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

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	04/18/2023

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