Provider Demographics
NPI:1184352296
Name:MCMULLEN, KONICA SHANNON (DNP)
Entity type:Individual
Prefix:
First Name:KONICA
Middle Name:SHANNON
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 MOSS ROSE DR
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-8340
Mailing Address - Country:US
Mailing Address - Phone:205-310-2600
Mailing Address - Fax:205-236-1724
Practice Address - Street 1:1769 MOSS ROSE DR
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-8340
Practice Address - Country:US
Practice Address - Phone:205-310-2600
Practice Address - Fax:205-236-1724
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-093551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-90226OtherBCBS-AL
AL299342Medicaid