Provider Demographics
NPI:1174284160
Name:MULLALLY, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MULLALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1441
Mailing Address - Country:US
Mailing Address - Phone:508-440-9426
Mailing Address - Fax:
Practice Address - Street 1:3 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1441
Practice Address - Country:US
Practice Address - Phone:508-440-9426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0510-2022Medicaid
MA0510-2022Medicaid
ME0510-2022Medicaid