Provider Demographics
NPI:1326470832
Name:MCNULTY, MARILYN (NP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:MCNULTY
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 1:5875 BREMO RD
Mailing Address - Street 2:SUITE G-5
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-287-7840
Mailing Address - Fax:804-287-7845
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE G-5
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-287-7840
Practice Address - Fax:804-287-7845
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171047363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN