Provider Demographics
NPI:1306897111
Name:MULLINS, TIFFANI LYNNE SCHAMMEL (PAC)
Entity type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:LYNNE SCHAMMEL
Last Name:MULLINS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:TIFFANI
Other - Middle Name:LYNNE
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:3257 WOOD DUCK DR NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3211
Mailing Address - Country:US
Mailing Address - Phone:952-447-2895
Mailing Address - Fax:
Practice Address - Street 1:8225 FLYING CLOUD DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5315
Practice Address - Country:US
Practice Address - Phone:952-944-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9320363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03550Medicare UPIN