Provider Demographics
NPI:1851443410
Name:MULLINS, KRYSTINE M (AUD, CCC/A)
Entity Type:Individual
Prefix:
First Name:KRYSTINE
Middle Name:M
Last Name:MULLINS
Suffix:
Gender:F
Credentials:AUD, CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:630-933-4057
Practice Address - Street 1:25 N. WINFIELD ROAD
Practice Address - Street 2:SUITE 424
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001149231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
ILF400177515OtherMEDICARE PTAN (INDIVIDUAL)
ILF400177515OtherMEDICARE PTAN (INDIVIDUAL)