=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912902545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER E MULLENDORE DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2005
-----------------------------------------------------
Last Update Date | 12/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 THOMAS JOHNSON DR STE 204
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-695-9669
-----------------------------------------------------
Fax | 301-695-0346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 182 THOMAS JOHNSON DRIVE SUITE 204
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-695-9669
-----------------------------------------------------
Fax | 301-695-0346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 01423
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------