Provider Demographics
NPI:1619501335
Name:BRUNER, ASHLEY JORDAN
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JORDAN
Last Name:BRUNER
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 1:403 TALL OAK DR
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-1851
Mailing Address - Country:US
Mailing Address - Phone:919-319-4387
Mailing Address - Fax:
Practice Address - Street 1:323 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5019
Practice Address - Country:US
Practice Address - Phone:918-756-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist