Basic Information
| Provider Information | |||||||||
| NPI: | 1588741177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W. THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195267939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 PARK AVE W STE 200 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449061226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195256730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP-08630 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | NP08630 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2837498 | 05 | OH | MEDICAID |