Basic Information
| Provider Information | |||||||||
| NPI: | 1669992228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793513 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MANCHESTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469621857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609821994 | ||||||||
| FaxNumber: | 2604792936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11019604A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.