Provider Demographics
NPI:1588105746
Name:BUNDRENT, DANIELLE D (DNP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:D
Last Name:BUNDRENT
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY277495OtherSIHO
IN300002098Medicaid
KY000001077743OtherANTHEM
KYK222220OtherMEDICARE
IN300002098OtherMEDICAID
KY7100471000Medicaid
KY50125555OtherPASSPORT