Healthcare Provider Details

I. General information

NPI: 1346308350
Provider Name (Legal Business Name): THERESA RAEDEL RUNDELL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 W MAIN ST MSCH-14
GOLDENDALE WA
98620-9597
US

IV. Provider business mailing address

92 RUNDELL RD P.O. BOX 268
UNDERWOOD WA
98651-9110
US

V. Phone/Fax

Practice location:
  • Phone: 509-493-1558
  • Fax: 509-493-4025
Mailing address:
  • Phone: 509-637-0702
  • Fax: 509-493-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP30001463
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: