Provider Demographics
NPI:1588346654
Name:MUNDT, TIFFANY (NP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MUNDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-0350
Mailing Address - Fax:414-955-0094
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-0350
Practice Address - Fax:414-955-0094
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13438-33363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care