Provider Demographics
NPI:1679817522
Name:MULLANIX, MEGAN LOUISE (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOUISE
Last Name:MULLANIX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LOUISE
Other - Last Name:JANSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2006 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4622
Mailing Address - Country:US
Mailing Address - Phone:605-342-3110
Mailing Address - Fax:605-342-3110
Practice Address - Street 1:2006 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4622
Practice Address - Country:US
Practice Address - Phone:605-342-3110
Practice Address - Fax:605-342-3110
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0362225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant