Provider Demographics
NPI:1124397732
Name:MONDEAUX, LORI MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:MONDEAUX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N HADDON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2344
Mailing Address - Country:US
Mailing Address - Phone:609-571-8748
Mailing Address - Fax:
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00358000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered