Provider Demographics
NPI:1750500104
Name:MULLALLY, LAUREL JILL (NP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:JILL
Last Name:MULLALLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:2212 CAMINO DEL SOL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1321
Mailing Address - Country:US
Mailing Address - Phone:909-628-1201
Mailing Address - Fax:909-628-6712
Practice Address - Street 1:5130 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4130
Practice Address - Country:US
Practice Address - Phone:909-628-1201
Practice Address - Fax:909-062-8671
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA410836363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily