Provider Demographics
NPI:1659663805
Name:BRUNDRETT, SUE R (NP-C)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:R
Last Name:BRUNDRETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SUSANN
Other - Middle Name:R
Other - Last Name:BRUNDRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:4520S US HIGHWAY 281
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:TX
Mailing Address - Zip Code:78606-5205
Mailing Address - Country:US
Mailing Address - Phone:830-833-0510
Mailing Address - Fax:830-833-4307
Practice Address - Street 1:3144 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6802
Practice Address - Country:US
Practice Address - Phone:325-617-4594
Practice Address - Fax:325-617-4593
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX620325363L00000X
TXAP120270363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFO311218OtherCERTIFICATION