Basic Information
Provider Information | |||||||||
NPI: | 1033553045 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULLINS | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DECOSTE | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 909 | ||||||||
Address2: | SUITE 301 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 40201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026255584 | ||||||||
FaxNumber: | 5024262264 | ||||||||
Practice Location | |||||||||
Address1: | 530 SOUTH JACKSON STREET | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 40202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028525851 | ||||||||
FaxNumber: | 5028523762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2013 | ||||||||
LastUpdateDate: | 09/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1119402 | KY | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 3008708 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.