Healthcare Provider Details

I. General information

NPI: 1992204556
Provider Name (Legal Business Name): KEVIN JOSEPH LUNDELL FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 TABOR XING
TABOR CITY NC
28463-2705
US

IV. Provider business mailing address

PO BOX 6149
ALOHA OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 910-653-1901
  • Fax:
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201904622NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10171373
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: