Provider Demographics
NPI:1760614093
Name:BRUNER, LORETTA LIN (LMT)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:LIN
Last Name:BRUNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:LORETTA
Other - Middle Name:LIN
Other - Last Name:BRUNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2475 E NINE MILE RD STE K
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-7796
Mailing Address - Country:US
Mailing Address - Phone:850-549-3274
Mailing Address - Fax:
Practice Address - Street 1:2475 E NINE MILE RD STE K
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-7796
Practice Address - Country:US
Practice Address - Phone:850-549-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA44798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist