Provider Demographics
NPI:1437205416
Name:BUNGART, JEAN MARIE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:BUNGART
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MISS
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:425 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0914
Mailing Address - Country:US
Mailing Address - Phone:209-723-3769
Mailing Address - Fax:
Practice Address - Street 1:425 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0914
Practice Address - Country:US
Practice Address - Phone:209-723-3769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 183948164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5294237Medicaid