Provider Demographics
NPI:1760445803
Name:BRUNETTE, DONNA L (CRNA)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:L
Last Name:BRUNETTE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4718
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305-4718
Mailing Address - Country:US
Mailing Address - Phone:864-592-0586
Mailing Address - Fax:864-592-0586
Practice Address - Street 1:720 N PINE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3127
Practice Address - Country:US
Practice Address - Phone:864-560-5822
Practice Address - Fax:864-592-0586
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR67114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0868Medicaid
SCQ32197Medicare PIN
SCAN0868Medicaid