Basic Information
Provider Information | |||||||||
NPI: | 1427511260 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULLINIKS | ||||||||
FirstName: | JOHNNY | ||||||||
MiddleName: | GLENN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP, APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MULLINIKS | ||||||||
OtherFirstName: | JOHNNY | ||||||||
OtherMiddleName: | GLENN | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | I | ||||||||
OtherCredential: | FNP,APRN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 418 FOOT LOG LN | ||||||||
Address2: |   | ||||||||
City: | HOGANSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 302301145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7066680136 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 371 NEWNAN CROSSING BYP STE 103 | ||||||||
Address2: |   | ||||||||
City: | NEWNAN | ||||||||
State: | GA | ||||||||
PostalCode: | 302653888 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704008410 | ||||||||
FaxNumber: | 7704008414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2019 | ||||||||
LastUpdateDate: | 11/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN188123 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.