Healthcare Provider Details

I. General information

NPI: 1558110668
Provider Name (Legal Business Name): BRENNA KATHRYN AMUNDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5268
APO AP
96368-5142
US

IV. Provider business mailing address

1075 NW 16TH AVE APT 501
PORTLAND OR
97209-2357
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4817
  • Fax:
Mailing address:
  • Phone: 320-266-0249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12041
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: