Provider Demographics
NPI:1093271298
Name:MULLINIX, DESTINEE (PTA)
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:
Last Name:MULLINIX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10355 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:GREENTOP
Mailing Address - State:MO
Mailing Address - Zip Code:63546-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10355 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:GREENTOP
Practice Address - State:MO
Practice Address - Zip Code:63546-2112
Practice Address - Country:US
Practice Address - Phone:660-216-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018026836225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018026836OtherPTA