Provider Demographics
NPI:1356519797
Name:MUND, JEANNIE THERESE (MPA CLC RD CDN)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:THERESE
Last Name:MUND
Suffix:
Gender:F
Credentials:MPA CLC RD CDN
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 50273
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-0273
Mailing Address - Country:US
Mailing Address - Phone:347-423-4192
Mailing Address - Fax:
Practice Address - Street 1:19 SCHOHARIE ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4325
Practice Address - Country:US
Practice Address - Phone:347-423-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002995133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
707184OtherADA REGISTRATION