Healthcare Provider Details

I. General information

NPI: 1063830438
Provider Name (Legal Business Name): THELBEN MULLETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4744 41ST AVE SW STE 101
SEATTLE WA
98116-4566
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-5780
  • Fax: 206-320-5794
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60754595
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: