Basic Information
Provider Information | |||||||||
NPI: | 1164678124 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULKEY | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | THERESA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | IRVIN-MULKEY | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | THERESA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 188 | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856530188 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206824560 | ||||||||
FaxNumber: | 5206824570 | ||||||||
Practice Location | |||||||||
Address1: | 13644 N SANDARIO RD | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856538579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206824560 | ||||||||
FaxNumber: | 5206824570 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2008 | ||||||||
LastUpdateDate: | 08/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN116687 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.