Provider Demographics
NPI:1194028530
Name:MUNDY, STEPHANIE MICHELLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:MUNDY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53187-0444
Mailing Address - Country:US
Mailing Address - Phone:262-271-2141
Mailing Address - Fax:
Practice Address - Street 1:N68W35460 COUNTY ROAD K
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-1210
Practice Address - Country:US
Practice Address - Phone:262-966-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311978-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse