Provider Demographics
NPI:1376228528
Name:BRUNER, DEREK WAYNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:WAYNE
Last Name:BRUNER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2127
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-1711
Mailing Address - Country:US
Mailing Address - Phone:844-673-6968
Mailing Address - Fax:
Practice Address - Street 1:4655 SALISBURY RD STE 220
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0959
Practice Address - Country:US
Practice Address - Phone:352-239-5958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily