Provider Demographics
NPI:1639793995
Name:DENNULL, DESIREE M (FNP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:M
Last Name:DENNULL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:360-729-3185
Practice Address - Street 1:38843 DEXTER RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:OR
Practice Address - Zip Code:97431-9600
Practice Address - Country:US
Practice Address - Phone:541-937-2134
Practice Address - Fax:541-937-1370
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10000466363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program