Healthcare Provider Details

I. General information

NPI: 1467878264
Provider Name (Legal Business Name): KELLY MULLIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 07/31/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404-2303
US

IV. Provider business mailing address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404-2303
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8212
  • Fax:
Mailing address:
  • Phone: 310-582-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1811
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: