Provider Information for 1417297797
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KAITLYN MCNULTY
Other Names:Former Name:KAITLYN RUSSELLSex: Female
NPI: 1417297797
Last Updated: 2018-09-28
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||||||
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| NPI | 1417297797 | ||||||||||||||||
| Enumeration Date | 2013-02-22 | ||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||
| Sole Proprietor | NO | ||||||||||||||||
| Status | Active | ||||||||||||||||
| Mailing Address | PO BOX 452841 LOS ANGELES, CA 90045-8539 United States Phone: 518-878-9042 | Fax: | ||||||||||||||||
| Primary Practice Address | 323 N PRAIRIE AVE INGLEWOOD, CA 90301-4502 United States Phone: 310-846-2100 | Fax:310-846-2139 | ||||||||||||||||
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