Provider Demographics
NPI:1144674441
Name:MULLIN, MICHELLE (FNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MULLIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63188-0551
Mailing Address - Country:US
Mailing Address - Phone:314-898-1700
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:2220 LEMP AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2700
Practice Address - Country:US
Practice Address - Phone:314-898-1700
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016010736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016010736OtherLICENSE