Provider Demographics
NPI:1912550468
Name:MULLINS, MARY R (DNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:MULLINS
Suffix:
Gender:
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62693-0103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 E HARPOLE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62693-9718
Practice Address - Country:US
Practice Address - Phone:175-889-8712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019659363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health