Provider Demographics
NPI:1154935682
Name:MULLEN, STACI M (RN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:M
Last Name:MULLEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:M
Other - Last Name:FRENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:CANASERAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14822-0112
Mailing Address - Country:US
Mailing Address - Phone:607-545-6197
Mailing Address - Fax:
Practice Address - Street 1:49 SOUTH CHURCH ST
Practice Address - Street 2:
Practice Address - City:CANASERAGA
Practice Address - State:NY
Practice Address - Zip Code:14822
Practice Address - Country:US
Practice Address - Phone:607-545-6197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY617017163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse