Basic Information
| Provider Information | |||||||||
| NPI: | 1063744456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIS | ||||||||
| FirstName: | MENDY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C-PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BALDWIN | ||||||||
| OtherFirstName: | MENDY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | C-PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
| FaxNumber: | 8122548636 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 N WEST ST | ||||||||
| Address2: | |||||||||
| City: | ODON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475621032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126367300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2010 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001157A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200153250A | 05 | IN | MEDICAID |