Provider Demographics
NPI:1710486907
Name:MULHERN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MULHERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 MONUMENT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-2728
Mailing Address - Country:US
Mailing Address - Phone:508-212-3141
Mailing Address - Fax:
Practice Address - Street 1:1501 MAPLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:508-212-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant