Provider Demographics
NPI:1235111428
Name:MULLINS, BENNIE JOE JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BENNIE
Middle Name:JOE
Last Name:MULLINS
Suffix:JR
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:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:
Practice Address - Street 1:1755 HIGHWAY 34 E
Practice Address - Street 2:SUITE 1100
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5631
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113064367500000X
MO2004036293367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917249500Medicaid
P00340069Medicare PIN
MOP00435962Medicare PIN
MOS55F133Medicare PIN
MO825573155Medicare PIN
MOJ11F133Medicare PIN
MO825573155Medicare PIN