Provider Demographics
NPI:1831683861
Name:MULBERRYS MOBILE PROVIDER SERVICES
Entity type:Organization
Organization Name:MULBERRYS MOBILE PROVIDER SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MULBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN-BC
Authorized Official - Phone:352-358-8070
Mailing Address - Street 1:6435 SE US HIGHWAY 301
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-7309
Mailing Address - Country:US
Mailing Address - Phone:352-358-8070
Mailing Address - Fax:949-577-4783
Practice Address - Street 1:6435 SE US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:FL
Practice Address - Zip Code:32640-7309
Practice Address - Country:US
Practice Address - Phone:352-358-8070
Practice Address - Fax:949-577-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106245700Medicaid
FL107001000Medicaid