Provider Demographics
NPI:1245773035
Name:BRUNNER, JESSICA (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 ANDERSON ST # B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4247
Mailing Address - Country:US
Mailing Address - Phone:216-789-5589
Mailing Address - Fax:
Practice Address - Street 1:519 ANDERSON ST # B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4247
Practice Address - Country:US
Practice Address - Phone:216-789-5589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC227851163W00000X
390200000X
NC6324367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program