Provider Demographics
NPI:1912212143
Name:MUNDY, STEPHANIE L (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:MUNDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0347
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1545
Practice Address - Country:US
Practice Address - Phone:270-965-4377
Practice Address - Fax:270-965-9569
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1076284163W00000X
KY3006634363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100140490Medicaid
KY7100140490Medicaid
KYP400032299Medicare PIN
KYP400032300Medicare PIN
KYK128980Medicare PIN
KYK128981Medicare PIN