Provider Demographics
NPI:1134100241
Name:MUDD, CAROLINE B (NP)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:B
Last Name:MUDD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 OAK ST
Mailing Address - Street 2:SUITE 223E
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-586-3683
Mailing Address - Fax:508-586-6052
Practice Address - Street 1:830 OAK ST
Practice Address - Street 2:SUITE 223E
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1168
Practice Address - Country:US
Practice Address - Phone:508-586-3683
Practice Address - Fax:508-586-6052
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181344363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0379531Medicaid
MANP3323Medicare ID - Type Unspecified
MA0379531Medicaid