Provider Demographics
NPI:1932136264
Name:MULLINS, GRACE Y
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:Y
Last Name:MULLINS
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 1:47 CAVALIER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-3970
Mailing Address - Country:US
Mailing Address - Phone:859-282-2024
Mailing Address - Fax:859-282-6747
Practice Address - Street 1:47 CAVALIER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-3970
Practice Address - Country:US
Practice Address - Phone:859-282-2024
Practice Address - Fax:859-282-6747
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
0666706Medicare UPIN