Provider Demographics
NPI:1962425652
Name:LUNDERGARD, LUANNE M (NP)
Entity type:Individual
Prefix:
First Name:LUANNE
Middle Name:M
Last Name:LUNDERGARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16929 FRANCES ST
Mailing Address - Street 2:STE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-4683
Mailing Address - Country:US
Mailing Address - Phone:402-758-5821
Mailing Address - Fax:402-898-8380
Practice Address - Street 1:16929 FRANCES ST
Practice Address - Street 2:STE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-4683
Practice Address - Country:US
Practice Address - Phone:402-758-5821
Practice Address - Fax:402-898-8380
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110483363LA2200X
IAH070586363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE500020913OtherRAILROAD MEDICARE
NE10025353100Medicaid
NE1962425652OtherBCBS NE
NE098611097OtherMEDICARE PTAN
NE10025353100Medicaid
NE274671Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL