Provider Demographics
NPI:1538461926
Name:MULLICAN, KELLEY MARIE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:MULLICAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:KELLEY
Other - Middle Name:MARIE
Other - Last Name:MULLICAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1131 W NEW HAVEN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4055
Mailing Address - Country:US
Mailing Address - Phone:321-434-1744
Mailing Address - Fax:
Practice Address - Street 1:1131 W NEW HAVEN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4055
Practice Address - Country:US
Practice Address - Phone:321-434-1744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9180608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily