Provider Demographics
NPI:1174515332
Name:MULLEN, ELLEN SHEA (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:SHEA
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4041
Mailing Address - Country:US
Mailing Address - Phone:337-364-8566
Mailing Address - Fax:337-359-9024
Practice Address - Street 1:2312 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4064
Practice Address - Country:US
Practice Address - Phone:337-364-0938
Practice Address - Fax:337-359-9024
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1466352Medicaid
LA021129OtherSTATE LICENSE
LA1466352Medicaid
LA4J430Medicare PIN