Provider Demographics
NPI:1366433864
Name:PUDERBAUGH, KATHLEEN ANNETTE (ARNP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANNETTE
Last Name:PUDERBAUGH
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 1:6432 OLSON RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-8514
Mailing Address - Country:US
Mailing Address - Phone:360-383-0693
Mailing Address - Fax:360-383-0838
Practice Address - Street 1:6760 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-966-2106
Practice Address - Fax:360-966-2304
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003425363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPO4196Medicare UPIN