Provider Demographics
NPI:1427793710
Name:MENDENHALL, SETH M (PMHNP)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:M
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 W MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-1679
Mailing Address - Country:US
Mailing Address - Phone:217-257-2215
Mailing Address - Fax:
Practice Address - Street 1:1401 W AGENCY RD
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1643
Practice Address - Country:US
Practice Address - Phone:319-768-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAG170108363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty