Basic Information
| Provider Information | |||||||||
| NPI: | 1205483435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUDD | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN.CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228493 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454057538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377233276 | ||||||||
| FaxNumber: | 9377233277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.347058 | OH | N | Nursing Service Providers | Registered Nurse | 363LA2100X | APRN.CNP.025975 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0380709 | 05 | OH | MEDICAID |