Provider Demographics
NPI:1710963483
Name:WUNDERLICH, KAREN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:STOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:120 PARK LANE RD STE B202
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2450
Mailing Address - Country:US
Mailing Address - Phone:860-210-0082
Mailing Address - Fax:860-210-1633
Practice Address - Street 1:120 PARK LANE RD STE B202
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2450
Practice Address - Country:US
Practice Address - Phone:860-210-0082
Practice Address - Fax:860-210-1633
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF360330363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0E0161Medicare ID - Type Unspecified
P21331Medicare UPIN