Provider Demographics
NPI:1316723745
Name:RUNDBLAD, REBECCA LOUISE (FNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOUISE
Last Name:RUNDBLAD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WELLNESS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2156
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:
Practice Address - Street 1:1783 ROUTE 9
Practice Address - Street 2:SUITE 202
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-881-1091
Practice Address - Fax:518-881-0796
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350687363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily