Provider Demographics
NPI:1588757306
Name:MULLEN, KRISTINA L (PAC)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:L
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:C/O CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:2320 FREEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-814-6100
Practice Address - Fax:360-814-6110
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004818363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ40978Medicare UPIN