Basic Information
| Provider Information | |||||||||
| NPI: | 1588105746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNDRENT | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776347 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 E BROADWAY FL 4 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026292055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011198 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 277495 | 01 | KY | SIHO | OTHER | 300002098 | 05 | IN | MEDICAID | 000001077743 | 01 | KY | ANTHEM | OTHER | K222220 | 01 | KY | MEDICARE | OTHER | 300002098 | 01 | IN | MEDICAID | OTHER | 7100471000 | 05 | KY | MEDICAID | 50125555 | 01 | KY | PASSPORT | OTHER |