MEDICARE: KAWANA KESIA MULLINS PP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	053726831	GA

General Provider Information

NPI Number	:	1346740131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAWANA KESIA MULLINS PP

Provider Business Mailing Address
First Line	:	1103 S DAVIS ST
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701
Country	:	US
Telephone Number	:	229-894-9740
Fax Number	:

Provider Business Practice Location Address
First Line	:	1103 S DAVIS ST
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701
Country	:	US
Telephone Number	:	229-894-9740
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2018
Last Update Date	:	02/19/2018

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