Provider Demographics
NPI:1114313004
Name:MUKALIAN, NICOLE ANI (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANI
Last Name:MUKALIAN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:ANI
Other - Last Name:STEPANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:242 S 8TH ST
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5727
Mailing Address - Country:US
Mailing Address - Phone:516-455-5237
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:SUITE 320A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-8874
Practice Address - Fax:215-955-2340
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014722363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103188469Medicaid
PA500810Medicare PIN