Provider Demographics
NPI:1154524163
Name:MULLANE, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:MULLANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 SHATTALON DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2001
Mailing Address - Country:US
Mailing Address - Phone:336-924-9309
Mailing Address - Fax:336-924-0388
Practice Address - Street 1:4505 SHATTALON DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2001
Practice Address - Country:US
Practice Address - Phone:336-924-9309
Practice Address - Fax:336-924-0388
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5999225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211772Medicaid