Healthcare Provider Details

I. General information

NPI: 1336855758
Provider Name (Legal Business Name): JENNIFER YOOJIN MULLEN AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PINEVIEW DR STE 101
KERNERSVILLE NC
27284-3813
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-992-1351
  • Fax: 336-992-1361
Mailing address:
  • Phone: 336-992-1351
  • Fax: 336-992-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number295832
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5017606
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: