1063744456 NPI number — MRS. MENDY L MULLIS C-PA

Table of content: MRS. MENDY L MULLIS C-PA (NPI 1063744456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063744456 NPI number — MRS. MENDY L MULLIS C-PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIS
Provider First Name:
MENDY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
C-PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALDWIN
Provider Other First Name:
MENDY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
C-PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063744456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 760
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47501-0760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-254-2760
Provider Business Mailing Address Fax Number:
812-254-8636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 N WEST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47562-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-636-7300
Provider Business Practice Location Address Fax Number:
812-257-7073
Provider Enumeration Date:
02/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  10001157A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200153250A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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