Healthcare Provider Details

I. General information

NPI: 1710719810
Provider Name (Legal Business Name): BONNIE MULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 VIDETTE LN SE
OWENS CROSS ROADS AL
35763-8893
US

IV. Provider business mailing address

1321 BLEVINS GAP RD SE
HUNTSVILLE AL
35802-2709
US

V. Phone/Fax

Practice location:
  • Phone: 256-975-4566
  • Fax:
Mailing address:
  • Phone: 575-496-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-101093
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: