Healthcare Provider Details

I. General information

NPI: 1366433864
Provider Name (Legal Business Name): KATHLEEN ANNETTE PUDERBAUGH ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6760 MISSION RD
EVERSON WA
98247-9749
US

IV. Provider business mailing address

6432 OLSON RD
FERNDALE WA
98248-8514
US

V. Phone/Fax

Practice location:
  • Phone: 360-966-2106
  • Fax: 360-966-2304
Mailing address:
  • Phone: 360-383-0693
  • Fax: 360-383-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP30003425
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30003425
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: