Provider Demographics
NPI:1316654411
Name:MULLIN, PAMELA RENAE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:RENAE
Last Name:MULLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 VIRGINIA RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2656
Mailing Address - Country:US
Mailing Address - Phone:706-513-2342
Mailing Address - Fax:706-814-6974
Practice Address - Street 1:2801 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2656
Practice Address - Country:US
Practice Address - Phone:706-513-2342
Practice Address - Fax:706-814-6974
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA661268577AMedicaid