Provider Demographics
NPI:1720383391
Name:BRUNING, MADELEINE DISTASO (NP)
Entity Type:Individual
Prefix:DR
First Name:MADELEINE
Middle Name:DISTASO
Last Name:BRUNING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:IRD 116
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-2211
Mailing Address - Country:US
Mailing Address - Phone:323-226-5609
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:IRD 116
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-2211
Practice Address - Country:US
Practice Address - Phone:323-226-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269108363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics