Provider Demographics
NPI:1306981725
Name:MUDRICK, TANYA ELISE (CPM, LTM, LM)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:ELISE
Last Name:MUDRICK
Suffix:
Gender:F
Credentials:CPM, LTM, LM
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 596
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55943-0596
Mailing Address - Country:US
Mailing Address - Phone:507-896-4985
Mailing Address - Fax:
Practice Address - Street 1:50 W 2ND ST
Practice Address - Street 2:ROOM 108
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3440
Practice Address - Country:US
Practice Address - Phone:507-474-0233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1016176B00000X
WI15-049176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife