Provider Demographics
NPI:1306489869
Name:BUSH, KALIE MULLIS (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KALIE
Middle Name:MULLIS
Last Name:BUSH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 LUCKY ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1176
Mailing Address - Country:US
Mailing Address - Phone:678-488-2602
Mailing Address - Fax:
Practice Address - Street 1:1520 LUCKY ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1176
Practice Address - Country:US
Practice Address - Phone:770-710-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily