MEDICARE: JENNIFER MUNDY NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209007079	IL

General Provider Information

NPI Number	:	1265675490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MUNDY NP

Provider Business Mailing Address
First Line	:	1770 E LAKE SHORE DR
Second Line	:	SUITE 207
City	:	DECATUR
State	:	IL
Zip	:	62521-3831
Country	:	US
Telephone Number	:	217-429-9700
Fax Number	:	217-429-9702

Provider Business Practice Location Address
First Line	:	1770 E LAKE SHORE DR
Second Line	:	SUITE 207
City	:	DECATUR
State	:	IL
Zip	:	62521-3831
Country	:	US
Telephone Number	:	217-429-9700
Fax Number	:	217-429-9702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	04/08/2024

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