Provider Demographics
NPI:1669019972
Name:MCMULLEN, LUCIANN POULOPOULOS
Entity type:Individual
Prefix:
First Name:LUCIANN
Middle Name:POULOPOULOS
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 EDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1124
Mailing Address - Country:US
Mailing Address - Phone:617-327-3232
Mailing Address - Fax:
Practice Address - Street 1:236 BEECH ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3311
Practice Address - Country:US
Practice Address - Phone:617-635-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN233921163WS0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchool