Provider Demographics
NPI:1346308350
Name:RUNDELL, THERESA RAEDEL (ARNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:RAEDEL
Last Name:RUNDELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 RUNDELL RD
Mailing Address - Street 2:P.O. BOX 268
Mailing Address - City:UNDERWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98651-9110
Mailing Address - Country:US
Mailing Address - Phone:509-637-0702
Mailing Address - Fax:509-493-4025
Practice Address - Street 1:228 W MAIN ST
Practice Address - Street 2:MSCH-14
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9597
Practice Address - Country:US
Practice Address - Phone:509-493-1558
Practice Address - Fax:509-493-4025
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001463363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8602492Medicaid