Healthcare Provider Details

I. General information

NPI: 1386399053
Provider Name (Legal Business Name): STACY SPIVEY MULLINIX RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NORTH GREEN ST
BALTIMORE MD
21201
US

IV. Provider business mailing address

4062 RUSTICO RD
MIDDLE RIVER MD
21220-2342
US

V. Phone/Fax

Practice location:
  • Phone: 800-698-2411
  • Fax:
Mailing address:
  • Phone: 470-331-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR199869
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: