Provider Demographics
NPI:1003291840
Name:MONGERI-MCPHERSON, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:MONGERI-MCPHERSON
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 1:2401 W UNIVERSITY AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3428
Mailing Address - Country:US
Mailing Address - Phone:765-747-4409
Mailing Address - Fax:765-751-1701
Practice Address - Street 1:240 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-741-0359
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005907A363LP0808X
IN28174599A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program