Provider Demographics
NPI:1093148512
Name:MUNDT, STEPHANIE K (APNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:K
Last Name:MUNDT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:K
Other - Last Name:MORTENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:5412 US HIGHWAY 10 E
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-8559
Mailing Address - Country:US
Mailing Address - Phone:715-346-5243
Mailing Address - Fax:715-346-5419
Practice Address - Street 1:5412 US HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8559
Practice Address - Country:US
Practice Address - Phone:715-346-5243
Practice Address - Fax:715-346-5419
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5373363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI148158OtherWI STATE RN LIC
WI5373OtherWI STATE APNP LIC