Provider Demographics
NPI:1386186831
Name:MULLIS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MULLIS
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 1:2920 S MCINTIRE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4221
Mailing Address - Country:US
Mailing Address - Phone:812-353-2870
Mailing Address - Fax:812-353-2881
Practice Address - Street 1:2920 S MCINTIRE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-353-2870
Practice Address - Fax:812-353-2881
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006699A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily