Provider Demographics
NPI:1003656315
Name:MUTTER, MEGHAN ELIZABETH ELAINE
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ELIZABETH ELAINE
Last Name:MUTTER
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 1:101 WILLOW TRACE CIR APT 6
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8801
Mailing Address - Country:US
Mailing Address - Phone:336-705-5013
Mailing Address - Fax:
Practice Address - Street 1:101 WILLOW TRACE CIR APT 6
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8801
Practice Address - Country:US
Practice Address - Phone:336-705-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer