Basic Information
| Provider Information | |||||||||
| NPI: | 1336764406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | KESHIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238441121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2020 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 234522 | TN | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363L00000X | 27770 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 27770 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.