Provider Demographics
NPI:1710422621
Name:BRUN, ANGELA MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIE
Last Name:BRUN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:CHALTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:140 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6840
Mailing Address - Country:US
Mailing Address - Phone:715-650-0214
Mailing Address - Fax:
Practice Address - Street 1:916 S 10TH ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6502
Practice Address - Country:US
Practice Address - Phone:715-570-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-01
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134592163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse