Provider Demographics
NPI:1710445028
Name:GUNDERSON, AMY RUTH (BSN, RN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RUTH
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RUTH
Other - Last Name:SHADBURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:3415 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3371
Mailing Address - Country:US
Mailing Address - Phone:503-234-9591
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201408717RN163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics