Healthcare Provider Details

I. General information

NPI: 1740195775
Provider Name (Legal Business Name): MR. BRENTON CRAIG NUNDAHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10505 W CLEARWATER AVE
KENNEWICK WA
99336-8613
US

IV. Provider business mailing address

4203 W KENNEWICK AVE APT 42
KENNEWICK WA
99336-2898
US

V. Phone/Fax

Practice location:
  • Phone: 509-378-5553
  • Fax:
Mailing address:
  • Phone: 509-820-8775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: