Provider Demographics
NPI:1518380039
Name:BRUNDER, NICHEL CAMILLE
Entity Type:Individual
Prefix:
First Name:NICHEL
Middle Name:CAMILLE
Last Name:BRUNDER
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 1:1571 PROVIDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-5626
Mailing Address - Country:US
Mailing Address - Phone:407-290-8957
Mailing Address - Fax:
Practice Address - Street 1:1571 PROVIDENCE CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-5626
Practice Address - Country:US
Practice Address - Phone:407-290-8957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist