Provider Demographics
NPI:1740061555
Name:BRUNSON, NICOLE DAWN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 NETWORK PL APT 203C
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3174
Mailing Address - Country:US
Mailing Address - Phone:239-450-9452
Mailing Address - Fax:
Practice Address - Street 1:4001 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4808
Practice Address - Country:US
Practice Address - Phone:239-450-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer