Provider Demographics
NPI:1770092199
Name:BRUNNER, MISTY (LVN)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HIGHWAY 418 E
Mailing Address - Street 2:
Mailing Address - City:SILSBEE
Mailing Address - State:TX
Mailing Address - Zip Code:77656-3729
Mailing Address - Country:US
Mailing Address - Phone:409-386-1200
Mailing Address - Fax:409-386-1219
Practice Address - Street 1:280 HIGHWAY 418 E
Practice Address - Street 2:
Practice Address - City:SILSBEE
Practice Address - State:TX
Practice Address - Zip Code:77656-3729
Practice Address - Country:US
Practice Address - Phone:409-386-1200
Practice Address - Fax:409-386-1219
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208185164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse