Provider Demographics
NPI:1134523715
Name:BRUNNER, SHELLY (NP-C)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N DELAWARE ST
Mailing Address - Street 2:206
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-1576
Mailing Address - Country:US
Mailing Address - Phone:650-218-5830
Mailing Address - Fax:
Practice Address - Street 1:1661 SOQUEL DR
Practice Address - Street 2:BUILDING C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1709
Practice Address - Country:US
Practice Address - Phone:831-476-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13135363LA2200X, 363LW0102X
CA1630367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife