Basic Information
| Provider Information | |||||||||
| NPI: | 1912381443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNDT | ||||||||
| FirstName: | CARMEN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | 4150 KIMBALL AVENUE | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192355390 | ||||||||
| FaxNumber: | 3192331630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1753 W RIDGEWAY AVE | ||||||||
| Address2: | STE 107 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507014544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198335907 | ||||||||
| FaxNumber: | 3198335908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | H091730 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.