Provider Demographics
NPI:1477249894
Name:MULLEN, NICOLE LYNNETTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNNETTE
Last Name:MULLEN
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 1:10416 EL NOPAL
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-4907
Mailing Address - Country:US
Mailing Address - Phone:619-954-3976
Mailing Address - Fax:
Practice Address - Street 1:10631 TIERRASANTA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2605
Practice Address - Country:US
Practice Address - Phone:858-576-0972
Practice Address - Fax:858-576-0035
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA183536183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician