Provider Demographics
NPI:1134659527
Name:MULLEN, KENNETH JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:MULLEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 KITTRELL FARMS DR APT 5
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9514
Mailing Address - Country:US
Mailing Address - Phone:336-534-7266
Mailing Address - Fax:
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-634-6638
Practice Address - Fax:252-464-4594
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC116884367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered