Provider Demographics
NPI:1255379699
Name:MUNDT, CARLA ANN (APRN)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:ANN
Last Name:MUNDT
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 1:4601 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3511
Mailing Address - Country:US
Mailing Address - Phone:520-399-6000
Mailing Address - Fax:
Practice Address - Street 1:4601 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3511
Practice Address - Country:US
Practice Address - Phone:520-399-6000
Practice Address - Fax:520-399-6002
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110418363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025224900Medicaid
NE47037661200Medicaid
NE10025225100Medicaid
NE47037661202Medicaid
NE276139Medicare ID - Type Unspecified
NE10025224900Medicaid
P74512Medicare UPIN