Provider Demographics
NPI:1336659788
Name:MUNDY, LORI FAITH (RN, CDE)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:FAITH
Last Name:MUNDY
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25980 SC HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:SILVERSTREET
Mailing Address - State:SC
Mailing Address - Zip Code:29145-9056
Mailing Address - Country:US
Mailing Address - Phone:803-944-0427
Mailing Address - Fax:
Practice Address - Street 1:905 POPE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-1928
Practice Address - Country:US
Practice Address - Phone:803-944-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC215908163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty