Provider Demographics
NPI:1578956454
Name:MUNDINGER, SHAUNA RAE
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:RAE
Last Name:MUNDINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5811
Mailing Address - Country:US
Mailing Address - Phone:858-997-9320
Mailing Address - Fax:
Practice Address - Street 1:1022 19TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5811
Practice Address - Country:US
Practice Address - Phone:858-997-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5028-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400208789Medicare PIN