Provider Demographics
NPI:1629696232
Name:MUNDANCHIRA, LORRAINE
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:MUNDANCHIRA
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 1:18 CARLTON DR
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-7910
Mailing Address - Country:US
Mailing Address - Phone:973-715-0413
Mailing Address - Fax:
Practice Address - Street 1:560 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3917
Practice Address - Country:US
Practice Address - Phone:212-305-4318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY790324163WC0200X
NJ26NR18930800367500000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered