Provider Demographics
NPI:1366779605
Name:MULLANACK, SUSAN THERESA (LMT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:THERESA
Last Name:MULLANACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4695 SEMINOLE ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951
Mailing Address - Country:US
Mailing Address - Phone:772-584-0794
Mailing Address - Fax:
Practice Address - Street 1:4695 SEMINOLE ROAD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34951
Practice Address - Country:US
Practice Address - Phone:772-584-0794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 54135175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath