Healthcare Provider Details

I. General information

NPI: 1093431918
Provider Name (Legal Business Name): MICKEY MASON MULLER DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

IV. Provider business mailing address

415 DAIRYLAND AVE
MILLTOWN WI
54858-9017
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax:
Mailing address:
  • Phone: 715-553-1285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9597
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: