Provider Demographics
NPI:1861558850
Name:MULLEN, MINDY MARIE
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:MARIE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BUCKTON RD
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:NY
Mailing Address - Zip Code:13697-3136
Mailing Address - Country:US
Mailing Address - Phone:315-389-4127
Mailing Address - Fax:
Practice Address - Street 1:2383 STATE ROUTE 95
Practice Address - Street 2:
Practice Address - City:BOMBAY
Practice Address - State:NY
Practice Address - Zip Code:12914-2017
Practice Address - Country:US
Practice Address - Phone:518-385-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268675-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse