Provider Demographics
NPI:1518919539
Name:MCMULLEN, TRACEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23560 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9229
Mailing Address - Country:US
Mailing Address - Phone:734-755-9677
Mailing Address - Fax:
Practice Address - Street 1:23560 13 MILE RD
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9229
Practice Address - Country:US
Practice Address - Phone:734-755-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169891367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered