Individual
DR. DANETTE RAI ELLIOTT-MULLENS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
2650 NE COURTNEY DR, BEND, OR 97701-7636
(541) 647-5200
Mailing address
660 MASON RIDGE CENTER DR STE 300, SAINT LOUIS, MO 63141-8512
(314) 448-3791
(314) 996-7658
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
DO150943
OR
207R00000X
Internal Medicine Physician
K9775
TX
2080A0000X
Pediatric Adolescent Medicine Physician
DO150943
OR
2080A0000X
Pediatric Adolescent Medicine Physician
K9775
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
143444105
—
TX
01
—
15402701
MEDICAID TPI BILLING NUMBER
TX
01
—
2023050669
MO STATE BOARD OF REGISTRATION
MO
05
—
500621599
—
OR
01
—
8AJ420
BCBS INDIV PROV #
TX
Enumeration date
07/19/2006
Last updated
04/11/2024
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