Provider Demographics
NPI:1942532734
Name:BUNDCHEN, INGE GISELA (FPMHNP-BC)
Entity type:Individual
Prefix:
First Name:INGE
Middle Name:GISELA
Last Name:BUNDCHEN
Suffix:
Gender:F
Credentials:FPMHNP-BC
Other - Prefix:
Other - First Name:INGE
Other - Middle Name:HORWATH
Other - Last Name:ZWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2983 LA QUESTA
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-6429
Mailing Address - Country:US
Mailing Address - Phone:928-899-7784
Mailing Address - Fax:
Practice Address - Street 1:143 N MCCORMICK ST
Practice Address - Street 2:#103
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2723
Practice Address - Country:US
Practice Address - Phone:928-899-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4183363LP0808X
AZRN137551163W00000X
COSXP-100025363LP0808X
COSNP-100051363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse