Provider Demographics
NPI:1073260824
Name:RUNDSTROM, KERRI SHEPHEARD (NP)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:SHEPHEARD
Last Name:RUNDSTROM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:LYNN
Other - Last Name:SHEPHEARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 GREEN SHUTTERS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE COURT HOUSE
Mailing Address - State:VA
Mailing Address - Zip Code:23923-3309
Mailing Address - Country:US
Mailing Address - Phone:434-315-4282
Mailing Address - Fax:
Practice Address - Street 1:104 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:BROOKNEAL
Practice Address - State:VA
Practice Address - Zip Code:24528-2643
Practice Address - Country:US
Practice Address - Phone:434-376-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily