=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205486362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALIE MULKEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2019
-----------------------------------------------------
Last Update Date | 10/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 PINE ST STE L40
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31201-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-633-1190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 ROBBIE CT
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-346-9605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 9408
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------