Provider Demographics
NPI:1356532691
Name:MOUILLESSEAUX, CORTNEY LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:CORTNEY
Middle Name:LYNN
Last Name:MOUILLESSEAUX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:LYNN
Other - Last Name:KIRKENDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:260 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4922
Mailing Address - Country:US
Mailing Address - Phone:919-488-0015
Mailing Address - Fax:919-277-0066
Practice Address - Street 1:270 HORIZON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4922
Practice Address - Country:US
Practice Address - Phone:919-845-0623
Practice Address - Fax:919-488-1716
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC201101853208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921418Medicaid