Provider Demographics
NPI:1346322377
Name:MULLIGAN, MICHELLE MARY
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARY
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BROADWAY STE 1200
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3450
Mailing Address - Country:US
Mailing Address - Phone:203-524-4309
Mailing Address - Fax:
Practice Address - Street 1:1115 BROADWAY STE 1200
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3450
Practice Address - Country:US
Practice Address - Phone:203-524-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily