Provider Demographics
NPI:1245567197
Name:SUNDAHL, VIRGIE KATHLEEN (RN)
Entity Type:Individual
Prefix:
First Name:VIRGIE
Middle Name:KATHLEEN
Last Name:SUNDAHL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:IMBODEN
Mailing Address - State:AR
Mailing Address - Zip Code:72434-9099
Mailing Address - Country:US
Mailing Address - Phone:870-869-1500
Mailing Address - Fax:870-869-1505
Practice Address - Street 1:609 W 3RD ST
Practice Address - Street 2:
Practice Address - City:IMBODEN
Practice Address - State:AR
Practice Address - Zip Code:72434-9099
Practice Address - Country:US
Practice Address - Phone:870-869-1500
Practice Address - Fax:870-869-1505
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR72458163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169349795Medicaid