Provider Demographics
NPI:1962930578
Name:MUNDLE, NICOLE ANN-MARIE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN-MARIE
Last Name:MUNDLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2404
Mailing Address - Country:US
Mailing Address - Phone:347-423-2041
Mailing Address - Fax:
Practice Address - Street 1:1076 E 56TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2404
Practice Address - Country:US
Practice Address - Phone:347-423-2041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3079151363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care