Provider Demographics
NPI:1407690944
Name:FUNDERBURG, MICHELLE LYNN (BSN, RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:FUNDERBURG
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9593 W MONTEBELLO DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6692
Mailing Address - Country:US
Mailing Address - Phone:208-520-8839
Mailing Address - Fax:
Practice Address - Street 1:7632 SW DURHAM RD STE 105
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7597
Practice Address - Country:US
Practice Address - Phone:208-520-8839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID45697163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator