Provider Demographics
NPI:1477626117
Name:LUNDY, MARY E (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:LUNDY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COLLEGE DR N
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2925
Mailing Address - Country:US
Mailing Address - Phone:701-662-5874
Mailing Address - Fax:
Practice Address - Street 1:204 COLLEGE DR N
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2925
Practice Address - Country:US
Practice Address - Phone:701-662-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52224Medicaid
ND25150Medicare ID - Type Unspecified