Basic Information
| Provider Information | |||||||||
| NPI: | 1073260824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNDSTROM | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | SHEPHEARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEPHEARD | ||||||||
| OtherFirstName: | KERRI | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 140 GREEN SHUTTERS LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE COURT HOUSE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239233309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343154282 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 104 CAROLINA AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKNEAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245282643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343762325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2022 | ||||||||
| LastUpdateDate: | 03/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024183390 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.