Provider Demographics
NPI:1144336082
Name:MULLIS, ELLYN PEARSON (MD)
Entity type:Individual
Prefix:
First Name:ELLYN
Middle Name:PEARSON
Last Name:MULLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLYN
Other - Middle Name:BAIN
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1022 SHELTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-6826
Mailing Address - Country:US
Mailing Address - Phone:704-768-2088
Mailing Address - Fax:
Practice Address - Street 1:1022 SHELTON AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-6826
Practice Address - Country:US
Practice Address - Phone:704-768-2088
Practice Address - Fax:704-768-2081
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966391Medicaid
NCE10607Medicare UPIN