Provider Demographics
NPI:1235620592
Name:MULLIKIN, MALLORY PAIGE (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:PAIGE
Last Name:MULLIKIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 LAKEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5698
Mailing Address - Country:US
Mailing Address - Phone:707-765-3900
Mailing Address - Fax:
Practice Address - Street 1:3900 LAKEVILLE HWY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5698
Practice Address - Country:US
Practice Address - Phone:707-765-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily