Provider Demographics
NPI:1316948235
Name:RUNYON, THERESA (RN NP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RUNYON
Suffix:
Gender:F
Credentials:RN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 LA CASA VIA
Mailing Address - Street 2:STE 210
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3091
Mailing Address - Country:US
Mailing Address - Phone:925-944-0351
Mailing Address - Fax:925-944-1957
Practice Address - Street 1:112 LA CASA VIA
Practice Address - Street 2:STE 210
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3091
Practice Address - Country:US
Practice Address - Phone:925-944-0351
Practice Address - Fax:925-944-1957
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMD13953363L00000X
CARN43220163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0020610Medicaid
ZZZ29612ZMedicare ID - Type Unspecified
Q17083Medicare UPIN
CAGR0020610Medicaid