Basic Information
| Provider Information | |||||||||
| NPI: | 1457786501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUDD | ||||||||
| FirstName: | ALLYSON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122547310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1402 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475012122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122578636 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 28185076A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201193390 | 05 | IN | MEDICAID |