Healthcare Provider Details

I. General information

NPI: 1487617767
Provider Name (Legal Business Name): JANNELL LEANA CUDDY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 NE 139TH ST SUITE 280
VANCOUVER WA
98686-2719
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax: 360-604-1780
Mailing address:
  • Phone: 360-882-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2930AT
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60498245
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: