Provider Demographics
NPI:1871673186
Name:MONDT, ELAINE MARIE (CNNP)
Entity Type:Individual
Prefix:MISS
First Name:ELAINE
Middle Name:MARIE
Last Name:MONDT
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:33140 KARIN DR
Mailing Address - Street 2:APT. 211
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6250
Mailing Address - Country:US
Mailing Address - Phone:586-939-6391
Mailing Address - Fax:313-916-9485
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:DIVISION OF NEONATOLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-3146
Practice Address - Fax:313-916-9485
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704132208363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ24657040Medicare PIN