Healthcare Provider Details

I. General information

NPI: 1902334816
Provider Name (Legal Business Name): MICHELLE LYNN MULLINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S TERRY AVE STE 320
ORLANDO FL
32805-1843
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 844-407-4070
  • Fax:
Mailing address:
  • Phone: 609-677-7003
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME151417
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: