Provider Demographics
NPI:1467610105
Name:MULLEN, LIZETTE L (LAC, MSOM)
Entity Type:Individual
Prefix:MS
First Name:LIZETTE
Middle Name:L
Last Name:MULLEN
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3177 S WOLLMER RD
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3177 S WOLLMER RD
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-4012
Practice Address - Country:US
Practice Address - Phone:414-852-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI375-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist