Provider Demographics
NPI:1902686603
Name:MULLENNIX, SUZANN MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:SUZANN
Middle Name:MARIE
Last Name:MULLENNIX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 QUARTERLINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9124
Mailing Address - Country:US
Mailing Address - Phone:616-826-5114
Mailing Address - Fax:
Practice Address - Street 1:12 W WOOD ST
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-7023
Practice Address - Country:US
Practice Address - Phone:231-519-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist