Provider Demographics
NPI:1982056198
Name:MULLEN, KELLI (OD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PARKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-5837
Mailing Address - Country:US
Mailing Address - Phone:662-983-9205
Mailing Address - Fax:
Practice Address - Street 1:5901 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2858
Practice Address - Country:US
Practice Address - Phone:601-268-6698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist