Provider Demographics
NPI:1710382395
Name:MULLEN, AMY JEAN (ABOC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:MULLEN
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:168
Other - Middle Name:
Other - Last Name:OPTICAL LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6315 PEARL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3074
Mailing Address - Country:US
Mailing Address - Phone:440-613-5222
Mailing Address - Fax:
Practice Address - Street 1:6315 PEARL RD STE 206
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3074
Practice Address - Country:US
Practice Address - Phone:440-613-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OHOP.007004-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0338913Medicaid