Provider Demographics
NPI:1689290074
Name:MUNDY, GEM
Entity Type:Individual
Prefix:
First Name:GEM
Middle Name:
Last Name:MUNDY
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 1:5500 TABOR AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2124
Mailing Address - Country:US
Mailing Address - Phone:215-906-1932
Mailing Address - Fax:
Practice Address - Street 1:5500 TABOR AVE STE 301
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2124
Practice Address - Country:US
Practice Address - Phone:215-906-1932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN286258164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse