Provider Demographics
NPI:1659614725
Name:MIMS, MICHELLE MULLIN (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MULLIN
Last Name:MIMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:GRACE
Other - Last Name:MULLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4520 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-1528
Mailing Address - Country:US
Mailing Address - Phone:504-782-7190
Mailing Address - Fax:
Practice Address - Street 1:4225 LAPALCO BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4324
Practice Address - Country:US
Practice Address - Phone:504-782-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA301371208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program