Healthcare Provider Details

I. General information

NPI: 1689006389
Provider Name (Legal Business Name): LINDA ANN RUNDSTROM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 WHIPPLE ROAD BLANCHARD RESIDENCE
SOUTH HERO VT
05486
US

IV. Provider business mailing address

777 SWAMP RD
FAIRFIELD VT
05455-5480
US

V. Phone/Fax

Practice location:
  • Phone: 802-372-4020
  • Fax:
Mailing address:
  • Phone: 802-782-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number025.0006218
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: