Healthcare Provider Details

I. General information

NPI: 1952897118
Provider Name (Legal Business Name): JENNY MULLIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax:
Mailing address:
  • Phone: 877-668-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008297B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: