Provider Demographics
NPI:1528583382
Name:MULLOY, KIMBERLY A
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:MULLOY
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 1:12660 RIVERSIDE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3430
Mailing Address - Country:US
Mailing Address - Phone:818-761-1800
Mailing Address - Fax:
Practice Address - Street 1:12660 RIVERSIDE DR STE 110
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3430
Practice Address - Country:US
Practice Address - Phone:818-761-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-13
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
CAPA61300363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant