Provider Demographics
NPI:1619678141
Name:MULL, MARYLEE KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:MARYLEE
Middle Name:KATHLEEN
Last Name:MULL
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 1:3733 39TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-2345
Mailing Address - Country:US
Mailing Address - Phone:941-773-0318
Mailing Address - Fax:
Practice Address - Street 1:3733 39TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-2345
Practice Address - Country:US
Practice Address - Phone:941-773-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3019133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered