Healthcare Provider Details

I. General information

NPI: 1295591253
Provider Name (Legal Business Name): ALEXA BROOKE MULLALLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 BRABHAM AVE STE 100
JACKSONVILLE NC
28546-0202
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 910-332-3800
  • Fax: 910-251-0421
Mailing address:
  • Phone: 910-332-3800
  • Fax: 910-251-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14235
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: