Healthcare Provider Details

I. General information

NPI: 1134659527
Provider Name (Legal Business Name): KENNETH JAMES MULLEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NEUSE BLVD
NEW BERN NC
28560-3449
US

IV. Provider business mailing address

4104 KITTRELL FARMS DR APT 5
GREENVILLE NC
27858-9514
US

V. Phone/Fax

Practice location:
  • Phone: 252-634-6638
  • Fax: 252-464-4594
Mailing address:
  • Phone: 336-534-7266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number116884
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: