Provider Demographics
NPI:1740726405
Name:MULLINS-ZUGELDER, KEELAN
Entity type:Individual
Prefix:
First Name:KEELAN
Middle Name:
Last Name:MULLINS-ZUGELDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15751 SAN CARLOS BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3315
Mailing Address - Country:US
Mailing Address - Phone:239-337-2739
Mailing Address - Fax:
Practice Address - Street 1:15751 SAN CARLOS BLVD STE 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3315
Practice Address - Country:US
Practice Address - Phone:239-337-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL36167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program