Provider Demographics
NPI:1629678388
Name:MULLETT, GREGORY KEITH
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:MULLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45602 ROUTE 52
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674-8041
Mailing Address - Country:US
Mailing Address - Phone:304-393-6340
Mailing Address - Fax:
Practice Address - Street 1:45602 ROUTE 52
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-8041
Practice Address - Country:US
Practice Address - Phone:304-393-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant