Provider Demographics
NPI:1063744456
Name:MULLIS, MENDY L (C-PA)
Entity type:Individual
Prefix:MRS
First Name:MENDY
Middle Name:L
Last Name:MULLIS
Suffix:
Gender:F
Credentials:C-PA
Other - Prefix:MS
Other - First Name:MENDY
Other - Middle Name:L
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:C-PA
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0760
Mailing Address - Country:US
Mailing Address - Phone:812-254-2760
Mailing Address - Fax:812-254-8636
Practice Address - Street 1:202 N WEST ST
Practice Address - Street 2:
Practice Address - City:ODON
Practice Address - State:IN
Practice Address - Zip Code:47562-1032
Practice Address - Country:US
Practice Address - Phone:812-636-7300
Practice Address - Fax:812-257-7073
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001157A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200153250AMedicaid
IN171520EMedicare Oscar/Certification
IN204330Medicare Oscar/Certification
INM100055499Medicare PIN
IN200153250AMedicaid