Healthcare Provider Details

I. General information

NPI: 1821091547
Provider Name (Legal Business Name): MARILYN KAY MULLANE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 W SALEM AVE
WINSTON SALEM NC
27101-5861
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-721-2375
  • Fax: 336-721-2394
Mailing address:
  • Phone: 336-766-0547
  • Fax: 336-766-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number101138
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101138
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: