Provider Demographics
NPI:1679706139
Name:MULVANEY, ANNIE M (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:M
Last Name:MULVANEY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:MACDOUGALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:347 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:973-498-0535
Practice Address - Street 1:347 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:973-498-0535
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00223900363A00000X
25MA05757000363A00000X
NJ25MA05757000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ195818NR4Medicare PIN