Provider Demographics
NPI:1164732699
Name:BRUNDIGE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRUNDIGE
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 1:101 DOUBLE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:FERNLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89408-9345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1666
Practice Address - Country:US
Practice Address - Phone:775-688-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner