Healthcare Provider Details

I. General information

NPI: 1740260835
Provider Name (Legal Business Name): STEPHANIE M MULLINS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BOONE RIDGE DR SUITE 201
JOHNSON CITY TN
37615-4998
US

IV. Provider business mailing address

PO BOX 2503
JOHNSON CITY TN
37605-2503
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-1145
  • Fax: 423-928-1353
Mailing address:
  • Phone: 423-928-1145
  • Fax: 423-928-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number121585
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: