Basic Information
| Provider Information | |||||||||
| NPI: | 1619283769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | RN, MSN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 2335 CHESTERFIELD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043462284 | ||||||||
| FaxNumber: | 3043466590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 11/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 37430 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3810020023 | 05 | WV | MEDICAID | P01087432 | 01 | WV | MEDICARE RAILROAD | OTHER |