Provider Demographics
NPI:1700331071
Name:MULLEN, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MULLEN
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 1:641 TRACEY JEAN CT
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8685
Mailing Address - Country:US
Mailing Address - Phone:209-640-7414
Mailing Address - Fax:
Practice Address - Street 1:641 TRACEY JEAN CT
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8685
Practice Address - Country:US
Practice Address - Phone:209-640-7414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397003708310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility