Provider Demographics
NPI:1295338119
Name:MULLENS, MELISSA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MULLENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MCWATTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 650
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2929
Mailing Address - Country:US
Mailing Address - Phone:312-926-0159
Mailing Address - Fax:312-695-4955
Practice Address - Street 1:676 N SAINT CLAIR ST STE 650
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2929
Practice Address - Country:US
Practice Address - Phone:312-926-0159
Practice Address - Fax:312-695-4955
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008746363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant