Provider Demographics
NPI:1063689628
Name:MULL, PAMELA L (LSW-QBHP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:MULL
Suffix:
Gender:F
Credentials:LSW-QBHP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW-QBHP
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1815 PLEASANT GROVE ROAD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22573-B171M00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174404795Medicaid