Provider Demographics
NPI:1033553045
Name:MULLINS, JESSICA LEIGH (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:MULLINS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:DECOSTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:P.O. BOX 909
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201
Mailing Address - Country:US
Mailing Address - Phone:502-625-5584
Mailing Address - Fax:502-426-2264
Practice Address - Street 1:530 SOUTH JACKSON STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-852-5851
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:No
Enumeration Date:2013-04-20
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1119402163W00000X
KY3008708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse