Provider Demographics
NPI:1194514513
Name:MULLIGAN, TRACI
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:
Last Name:MULLIGAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:ZIZZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FDN-P
Mailing Address - Street 1:474 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-4709
Mailing Address - Country:US
Mailing Address - Phone:631-495-1144
Mailing Address - Fax:
Practice Address - Street 1:271 ROUTE 25A STE 1
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2073
Practice Address - Country:US
Practice Address - Phone:631-495-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach