Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | MA 54135 | FL |
NPI | 1366779605 |
---|---|
Provider Name | Susan Theresa Mullanack |
First Address | Fort Pierce, FL 34951 |
Second Address | Fort Pierce, FL 34951 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2009 |
Last Update Date | 06/11/2009 |