Provider Demographics
NPI:1457397622
Name:BRUNS, MAUREEN ELIZABETH (MS, RD, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ELIZABETH
Last Name:BRUNS
Suffix:
Gender:F
Credentials:MS, RD, PA-C
Other - Prefix:MS
Other - First Name:MAUREEN
Other - Middle Name:ELIZABETH
Other - Last Name:SPEDDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, PA-C
Mailing Address - Street 1:PO BOX 30148
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2053
Mailing Address - Country:US
Mailing Address - Phone:888-488-8289
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:42645 GARFIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5022
Practice Address - Country:US
Practice Address - Phone:586-286-7246
Practice Address - Fax:586-329-4757
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI896415133V00000X
MI5601004683363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1457397622Medicaid