Provider Demographics
NPI:1134773468
Name:MULLENNIX, STEPHANIE C (RN, CEN, AGCNS-BC)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:C
Last Name:MULLENNIX
Suffix:
Gender:F
Credentials:RN, CEN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8938 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9510
Mailing Address - Country:US
Mailing Address - Phone:616-325-0069
Mailing Address - Fax:
Practice Address - Street 1:4100 EMBASSY DR SE STE 400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2416
Practice Address - Country:US
Practice Address - Phone:616-988-8233
Practice Address - Fax:616-957-3320
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230534364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist