Provider Demographics
NPI:1245778505
Name:MCMULLEN, MARY CHRISTINA (LSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINA
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E WATERLOO RD STE 313
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-3856
Mailing Address - Country:US
Mailing Address - Phone:303-208-2720
Mailing Address - Fax:330-208-2721
Practice Address - Street 1:1560 CORPORATE WOODS PKWY STE 313
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685
Practice Address - Country:US
Practice Address - Phone:330-208-2720
Practice Address - Fax:330-208-2721
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020557363L00000X
OH371457363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273356Medicaid