Provider Demographics
NPI:1700282613
Name:MUNDY, NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5854 YERMO DR APT Q2
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-1641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 SUGAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:PEMBERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43450-8701
Practice Address - Country:US
Practice Address - Phone:419-833-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0037902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer