Provider Demographics
NPI:1316941891
Name:MULLEN, CONNIE (LM, CPM)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 NW 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-3238
Mailing Address - Country:US
Mailing Address - Phone:561-330-0993
Mailing Address - Fax:561-594-1807
Practice Address - Street 1:7950 S MILITARY TRL
Practice Address - Street 2:201
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8162
Practice Address - Country:US
Practice Address - Phone:561-330-0993
Practice Address - Fax:561-594-1807
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW45176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340011500Medicaid