Provider Demographics
NPI:1013345529
Name:BRUNSON, PAMELA CLOVER (ARNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:CLOVER
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16570 HIGHWAY 104 N
Mailing Address - Street 2:STE B
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-3877
Mailing Address - Country:US
Mailing Address - Phone:731-968-2233
Mailing Address - Fax:
Practice Address - Street 1:16570 HIGHWAY 104 N
Practice Address - Street 2:STE B
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-3877
Practice Address - Country:US
Practice Address - Phone:731-968-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9203441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009904700Medicaid