Provider Demographics
NPI:1518277714
Name:KILLEN, MARA DEVIN (DNP, WHNP)
Entity Type:Individual
Prefix:MISS
First Name:MARA
Middle Name:DEVIN
Last Name:KILLEN
Suffix:
Gender:F
Credentials:DNP, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5018 MERRIMAC CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1001
Mailing Address - Country:US
Mailing Address - Phone:610-420-4771
Mailing Address - Fax:
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 640
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-677-0777
Practice Address - Fax:858-677-0666
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004277363LW0102X
PASP010953363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA264293Medicare PIN