Provider Demographics
NPI:1366861049
Name:JOHNSON-BRUNNER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON-BRUNNER
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 1:55 RIVER DR S
Mailing Address - Street 2:# 209
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1712
Mailing Address - Country:US
Mailing Address - Phone:201-936-6606
Mailing Address - Fax:
Practice Address - Street 1:55 RIVER DR S
Practice Address - Street 2:# 209
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1712
Practice Address - Country:US
Practice Address - Phone:201-936-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1861464332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment