Provider Demographics
NPI:1659831642
Name:MULLIN, STACEY E (NP-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:MULLIN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 ROSEWOOD N
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 ROSEWOOD N
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5003
Practice Address - Country:US
Practice Address - Phone:989-775-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704298822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily