Provider Demographics
NPI:1548278443
Name:KWON, MANDY (NP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 SWEET MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3866
Mailing Address - Country:US
Mailing Address - Phone:928-412-0955
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:#518
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-257-9488
Practice Address - Fax:602-254-4258
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212273363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care