Healthcare Provider Details

I. General information

NPI: 1427793710
Provider Name (Legal Business Name): SETH M MENDENHALL PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 01/12/2023
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W AGENCY RD
WEST BURLINGTON IA
52655-1643
US

IV. Provider business mailing address

508 W MORNINGSIDE DR
BURLINGTON IA
52601-1679
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-4191
  • Fax:
Mailing address:
  • Phone: 217-257-2215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG170108
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: