Provider Demographics
NPI:1295289262
Name:BRUNEAU, SUSANNE
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:BRUNEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:E
Other - Last Name:HOTCHKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3630 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2609
Practice Address - Country:US
Practice Address - Phone:310-900-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA53832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program