Provider Demographics
NPI:1619643582
Name:MCMULLEN, TRACI L
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:MCMULLEN
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 1:24 THOMASTON LN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2526
Mailing Address - Country:US
Mailing Address - Phone:716-861-2386
Mailing Address - Fax:
Practice Address - Street 1:900 HERTEL AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216-2611
Practice Address - Country:US
Practice Address - Phone:716-871-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347789-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily