Healthcare Provider Details

I. General information

NPI: 1063744456
Provider Name (Legal Business Name): MENDY L MULLIS C-PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MENDY L BALDWIN C-PA

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N WEST ST
ODON IN
47562-1032
US

IV. Provider business mailing address

PO BOX 760
WASHINGTON IN
47501-0760
US

V. Phone/Fax

Practice location:
  • Phone: 812-636-7300
  • Fax: 812-257-7073
Mailing address:
  • Phone: 812-254-2760
  • Fax: 812-254-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001157A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: