Provider Demographics
NPI:1609113539
Name:MUDD, BIANCA MARIA (RN)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:MARIA
Last Name:MUDD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2003
Mailing Address - Country:US
Mailing Address - Phone:314-269-4287
Mailing Address - Fax:
Practice Address - Street 1:6121 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2003
Practice Address - Country:US
Practice Address - Phone:314-269-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012010818163W00000X, 405300000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty