Provider Demographics
NPI:1073080909
Name:BRUNO-RODGERS, KIERRA LA SHAWN
Entity Type:Individual
Prefix:
First Name:KIERRA
Middle Name:LA SHAWN
Last Name:BRUNO-RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 WINSTON LN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1620
Mailing Address - Country:US
Mailing Address - Phone:708-692-0728
Mailing Address - Fax:
Practice Address - Street 1:712 N DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3846
Practice Address - Country:US
Practice Address - Phone:708-692-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
IL238000612207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238000612OtherREGISTERED SURGICAL ASSISTANT