Basic Information
| Provider Information | |||||||||
| NPI: | 1215533088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMULLEN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA-S, CSA, MSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 FIRST COLONIAL RD STE A | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573951850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1020 FIRST COLONIAL RD STE A | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573951850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2020 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 0110007948 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.