Basic Information
| Provider Information | |||||||||
| NPI: | 1245778505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMULLEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHRISTINA | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 E WATERLOO RD STE 313 | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443123856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032082720 | ||||||||
| FaxNumber: | 3302082721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1560 CORPORATE WOODS PKWY STE 313 | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302082720 | ||||||||
| FaxNumber: | 3302082721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.020557 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 371457 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0273356 | 05 | OH | MEDICAID |