Provider Demographics
NPI:1356565600
Name:BRUNS, JESSICA LYNN (CST-FA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BRUNS
Suffix:
Gender:F
Credentials:CST-FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 MORTON PLANT ST STE 409
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3394
Mailing Address - Country:US
Mailing Address - Phone:727-449-2599
Mailing Address - Fax:
Practice Address - Street 1:1712 BELLEAIR FOREST DR APT C
Practice Address - Street 2:
Practice Address - City:BELLEAIR
Practice Address - State:FL
Practice Address - Zip Code:33756-7728
Practice Address - Country:US
Practice Address - Phone:727-512-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL87811246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL246Z50400XMedicare UPIN