Provider Demographics
NPI:1700016128
Name:MCMULLEN, TANIA R (CHA II-C)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:R
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:CHA II-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5530
Mailing Address - Street 2:
Mailing Address - City:PORT GRAHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99603-5530
Mailing Address - Country:US
Mailing Address - Phone:907-284-2241
Mailing Address - Fax:907-284-2277
Practice Address - Street 1:5530 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORT GRAHAM
Practice Address - State:AK
Practice Address - Zip Code:99603-5530
Practice Address - Country:US
Practice Address - Phone:907-284-2241
Practice Address - Fax:907-284-2277
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker