Provider Demographics
NPI:1972578912
Name:BRUNOZZI, STACEY L (CRNP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:BRUNOZZI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 2ND ST
Mailing Address - Street 2:324 KEHR UNION BUILDING
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1301
Mailing Address - Country:US
Mailing Address - Phone:570-389-4451
Mailing Address - Fax:570-389-3417
Practice Address - Street 1:400 E 2ND ST
Practice Address - Street 2:324 KEHR UNION BUILDING
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1301
Practice Address - Country:US
Practice Address - Phone:570-389-4451
Practice Address - Fax:570-389-3417
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008441363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q29274Medicare UPIN
PA085663Medicare ID - Type Unspecified