Provider Demographics
NPI:1316547649
Name:MCMULLEN, TABIA ONI (ACNP)
Entity Type:Individual
Prefix:
First Name:TABIA
Middle Name:ONI
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 ASHLEY PHOSPHATE RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-4403
Mailing Address - Country:US
Mailing Address - Phone:854-999-4899
Mailing Address - Fax:
Practice Address - Street 1:2850 ASHLEY PHOSPHATE RD STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-4403
Practice Address - Country:US
Practice Address - Phone:854-999-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24398363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNONEMedicaid