Provider Demographics
NPI:1710684428
Name:MULLENS, JOHN WILLIAM IV (AGACNP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:MULLENS
Suffix:IV
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:200 S ENOTA DR NE STE 100
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3466
Practice Address - Country:US
Practice Address - Phone:770-534-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN289159163W00000X, 363LA2100X
GA2023000291363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2023000291OtherAMERICAN NURSING CREDENTIALING CENTER
GARN289159OtherGEORGIA BOARD OF NURSING