Provider Demographics
NPI:1316390917
Name:MULLEN, MICHAEL CAMPBELL (HIS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CAMPBELL
Last Name:MULLEN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 BLANKENBAKER PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40243
Mailing Address - Country:US
Mailing Address - Phone:502-245-5101
Mailing Address - Fax:
Practice Address - Street 1:406 BLANKENBAKER PKWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:KY
Practice Address - Zip Code:40243-1881
Practice Address - Country:US
Practice Address - Phone:502-245-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0975237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist