Basic Information
| Provider Information | |||||||||
| NPI: | 1093918336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNNELLS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671142037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162821950 | ||||||||
| FaxNumber: | 3162834054 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671142037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162821950 | ||||||||
| FaxNumber: | 3162834054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 13-73778-071 | KS | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.