Provider Demographics
NPI:1912230186
Name:MONDERO, CARIE ANN (CNM)
Entity Type:Individual
Prefix:
First Name:CARIE
Middle Name:ANN
Last Name:MONDERO
Suffix:
Gender:F
Credentials:CNM
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1630 LAFAYETTE RD STE 400
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1095
Practice Address - Country:US
Practice Address - Phone:765-428-5888
Practice Address - Fax:765-361-2086
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000145A367A00000X
IL209007251367A00000X
IN71004794A176B00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN471400417OtherMEDICARE PTAN
IN201220170Medicaid