Provider Demographics
NPI:1801665542
Name:MONDSHINE, SYDNEY (PA)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:MONDSHINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8658 TRADEWIND CIR APT 404
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-2943
Mailing Address - Country:US
Mailing Address - Phone:832-314-8163
Mailing Address - Fax:
Practice Address - Street 1:17 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4251
Practice Address - Country:US
Practice Address - Phone:423-717-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant