Healthcare Provider Details

I. General information

NPI: 1992209324
Provider Name (Legal Business Name): MALLORY NICOLE MULLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 BEAUMONT CENTRE CIR
LEXINGTON KY
40513-1957
US

IV. Provider business mailing address

3175 BEAUMONT CENTRE CIR
LEXINGTON KY
40513-1957
US

V. Phone/Fax

Practice location:
  • Phone: 859-576-0058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number3012151
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012151
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: