Provider Demographics
NPI:1336755610
Name:BRUNSON, SHANTA (HOME HEALTH AGENCY)
Entity Type:Individual
Prefix:PROF
First Name:SHANTA
Middle Name:
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:HOME HEALTH AGENCY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-2937
Mailing Address - Country:US
Mailing Address - Phone:219-413-1220
Mailing Address - Fax:
Practice Address - Street 1:601 S LAKE ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2937
Practice Address - Country:US
Practice Address - Phone:219-413-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN229006172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker