Provider Demographics
NPI:1659321974
Name:O'CONNOR-MULLEN, KATHLEEN A (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:O'CONNOR-MULLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 METZGER DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2018
Mailing Address - Country:US
Mailing Address - Phone:716-662-0269
Mailing Address - Fax:
Practice Address - Street 1:1825 MAPLE RD
Practice Address - Street 2:SUITE LLB
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2723
Practice Address - Country:US
Practice Address - Phone:716-204-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3311582363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01701160Medicaid