Provider Demographics
NPI:1336642339
Name:MULLIGAN, KERRI S (RD)
Entity Type:Individual
Prefix:MS
First Name:KERRI
Middle Name:S
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:KERRI
Other - Middle Name:S
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8842 WINDING WAY APT 446
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6498
Mailing Address - Country:US
Mailing Address - Phone:210-540-3885
Mailing Address - Fax:
Practice Address - Street 1:8080 MADISON AVE STE 200D
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3736
Practice Address - Country:US
Practice Address - Phone:210-540-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86030089133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered