Healthcare Provider Details

I. General information

NPI: 1457631780
Provider Name (Legal Business Name): JENNY FAYE MULLINS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 E MAIN ST
HAZARD KY
41701-1973
US

IV. Provider business mailing address

279 E MAIN ST
HAZARD KY
41701-1973
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-9505
  • Fax: 606-436-0071
Mailing address:
  • Phone: 606-487-9505
  • Fax: 606-436-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03746
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: