Provider Demographics
NPI:1255006524
Name:MULLEN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MULLEN
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 1:20031 KNOBLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEW CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26743-4654
Mailing Address - Country:US
Mailing Address - Phone:681-620-6018
Mailing Address - Fax:
Practice Address - Street 1:20031 KNOBLEY RD
Practice Address - Street 2:
Practice Address - City:NEW CREEK
Practice Address - State:WV
Practice Address - Zip Code:26743-4654
Practice Address - Country:US
Practice Address - Phone:681-620-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker