Provider Demographics
NPI:1639632391
Name:MULLIS, KIERSTEN P (DO)
Entity Type:Individual
Prefix:DR
First Name:KIERSTEN
Middle Name:P
Last Name:MULLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:439 US HWY 158 WEST
Practice Address - Street 2:
Practice Address - City:YANCEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-1007
Practice Address - Country:US
Practice Address - Phone:336-694-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC250906207Q00000X
390200000X
NC2021-02336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program