Provider Demographics
NPI:1407148190
Name:MULLIGAN, KRISTI ANN (OTRL)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:ANN
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1511
Mailing Address - Country:US
Mailing Address - Phone:248-446-9883
Mailing Address - Fax:
Practice Address - Street 1:379 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1511
Practice Address - Country:US
Practice Address - Phone:248-446-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006241172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker