Healthcare Provider Details

I. General information

NPI: 1538090998
Provider Name (Legal Business Name): GRACE MULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 25TH AVE S
MINNEAPOLIS MN
55454-1513
US

IV. Provider business mailing address

401 S 1ST ST UNIT 120
MINNEAPOLIS MN
55401-2561
US

V. Phone/Fax

Practice location:
  • Phone: 612-330-1388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: