Provider Demographics
NPI:1346390911
Name:MULLINS, NICOLE (MPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MULLINS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7907 FORRESTAL RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-1711
Mailing Address - Country:US
Mailing Address - Phone:619-847-8774
Mailing Address - Fax:619-692-4148
Practice Address - Street 1:2831 CAMINO DEL RIO S STE 111
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3827
Practice Address - Country:US
Practice Address - Phone:619-340-0400
Practice Address - Fax:619-340-0407
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21308Medicare ID - Type UnspecifiedPHYSICAL THERAPIST