Provider Demographics
NPI:1235531773
Name:MULLINS, CHRYSTAH
Entity Type:Individual
Prefix:
First Name:CHRYSTAH
Middle Name:
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GIBSON LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2577
Mailing Address - Country:US
Mailing Address - Phone:859-623-6401
Mailing Address - Fax:
Practice Address - Street 1:415 GIBSON LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2577
Practice Address - Country:US
Practice Address - Phone:859-623-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid