1538313457 NPI number — MS. GINA MARIE MUNDELL FNP

Table of content: MS. GINA MARIE MUNDELL FNP (NPI 1538313457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538313457 NPI number — MS. GINA MARIE MUNDELL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDELL
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538313457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2920 N CASCADE AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80907-6262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-636-1201
Provider Business Mailing Address Fax Number:
719-955-0986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2920 N CASCADE AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907-6262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-636-1201
Provider Business Practice Location Address Fax Number:
719-955-0986
Provider Enumeration Date:
11/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  125863 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APN.0005322 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 69171751 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".