Provider Demographics
NPI:1881703940
Name:BOYD-MULLINEAUX, JENNIFER L (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BOYD-MULLINEAUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BOYD-MULLINEAUX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:345 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2348
Mailing Address - Country:US
Mailing Address - Phone:203-752-8785
Mailing Address - Fax:203-752-3878
Practice Address - Street 1:211 STATE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4808
Practice Address - Country:US
Practice Address - Phone:203-366-0664
Practice Address - Fax:203-394-6784
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001304363A00000X
CT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ00531Medicare UPIN
CT97001425Medicare Oscar/Certification