Provider Demographics
NPI:1982097663
Name:MULLIKIN, SHELLY JEAN
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:JEAN
Last Name:MULLIKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:JEAN
Other - Last Name:WUTTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:210 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1914
Mailing Address - Country:US
Mailing Address - Phone:262-763-7177
Mailing Address - Fax:262-763-9860
Practice Address - Street 1:210 S PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1914
Practice Address - Country:US
Practice Address - Phone:262-763-7177
Practice Address - Fax:262-763-9860
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI318362OtherNABP