MEDICARE: DORENE JOYCE KNUDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0200X	Pediatric Registered Nurse	435886	TX

General Provider Information

NPI Number	:	1538642855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORENE JOYCE KNUDSON

Provider Business Mailing Address
First Line	:	2100 COMMONWEALTH ST UNIT N
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1868
Country	:	US
Telephone Number	:	713-630-0090
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 COMMONWEALTH ST UNIT N
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1868
Country	:	US
Telephone Number	:	713-630-0090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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