Provider Demographics
NPI:1538659479
Name:MUDD, JOHN PAUL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:MUDD
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 SAMUEL ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2458
Mailing Address - Country:US
Mailing Address - Phone:502-599-4949
Mailing Address - Fax:
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:502-287-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012234363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty