Provider Demographics
NPI:1497812192
Name:BRUNER, KERRY GAYLE (APN,FNP, BC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:GAYLE
Last Name:BRUNER
Suffix:
Gender:F
Credentials:APN,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 301
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505
Mailing Address - Country:US
Mailing Address - Phone:903-793-0122
Mailing Address - Fax:903-792-7630
Practice Address - Street 1:1000 PINE ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5100
Practice Address - Country:US
Practice Address - Phone:903-798-8000
Practice Address - Fax:903-798-7354
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX605480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150499758Medicaid
TX8A7807Medicare ID - Type Unspecified
TXP90629Medicare UPIN