Healthcare Provider Details

I. General information

NPI: 1457948366
Provider Name (Legal Business Name): CARLA MUNDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARLA KOWALEWSKI

II. Dates (important events)

Enumeration Date: 12/26/2020
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W ORANGE GROVE RD STE 105
TUCSON AZ
85704-1150
US

IV. Provider business mailing address

6912 S QUENTIN ST STE 50
CENTENNIAL CO
80112-4531
US

V. Phone/Fax

Practice location:
  • Phone: 520-526-9699
  • Fax:
Mailing address:
  • Phone: 720-282-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number249343
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number249343
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: