Provider Demographics
NPI:1679170336
Name:BRUNDAGE, BONNIE A
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:BRUNDAGE
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 1:113 PIERPOINT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-1239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 SOUTH COURT STREET
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362
Practice Address - Country:US
Practice Address - Phone:304-643-4941
Practice Address - Fax:304-643-4936
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant