Healthcare Provider Details

I. General information

NPI: 1104168905
Provider Name (Legal Business Name): JOHN HARRISON MULLINS III FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

400 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6035
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-6561
  • Fax:
Mailing address:
  • Phone: 423-431-6561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024170760
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17576
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: