Provider Demographics
NPI:1376285700
Name:MULLINS, LAUREN NICOLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
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 1:1212 OAKLAND RD SPC 14
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1304
Mailing Address - Country:US
Mailing Address - Phone:253-677-1827
Mailing Address - Fax:
Practice Address - Street 1:1212 OAKLAND RD SPC 14
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1304
Practice Address - Country:US
Practice Address - Phone:253-677-1827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant