Provider Demographics
NPI:1861057507
Name:FUDURICH, SHAWNEE RENEE (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAWNEE
Middle Name:RENEE
Last Name:FUDURICH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHAWNEE
Other - Middle Name:RENEE
Other - Last Name:BRUNNEMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28508 N 66TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-7599
Mailing Address - Country:US
Mailing Address - Phone:623-670-4324
Mailing Address - Fax:
Practice Address - Street 1:10230 W HAPPY VALLEY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-4255
Practice Address - Country:US
Practice Address - Phone:623-561-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ224194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily