Provider Demographics
NPI:1407977192
Name:MONDLAK, AYNESSA D (RN, MSN, C-FNP)
Entity Type:Individual
Prefix:MRS
First Name:AYNESSA
Middle Name:D
Last Name:MONDLAK
Suffix:
Gender:F
Credentials:RN, MSN, C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1241
Mailing Address - Country:US
Mailing Address - Phone:304-526-1872
Mailing Address - Fax:304-526-1809
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1872
Practice Address - Fax:304-526-1809
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1073953OtherWV COMPENSATION
OH000000272703OtherOH UNISON
WV613154600OtherFEDERAL BLACK LUNG/FECA
WV3810012715Medicaid
WV5100071Medicare ID - Type Unspecified
WV3810012715Medicaid
WVMONP78112Medicare PIN