Provider Demographics
NPI:1114545647
Name:MULLIS, ICIE HUTCHESON (APRN)
Entity Type:Individual
Prefix:
First Name:ICIE
Middle Name:HUTCHESON
Last Name:MULLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 GREGG ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2618
Mailing Address - Country:US
Mailing Address - Phone:803-779-5959
Mailing Address - Fax:803-799-9353
Practice Address - Street 1:1910 GREGG ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2618
Practice Address - Country:US
Practice Address - Phone:803-779-5959
Practice Address - Fax:803-799-9353
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC24046OtherAPRN
SC1114545647OtherNPI