Basic Information
| Provider Information | |||||||||
| NPI: | 1497812192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNER | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | GAYLE | ||||||||
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| Credential: | APN,FNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037930122 | ||||||||
| FaxNumber: | 9037927630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 PINE ST | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755015100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037988000 | ||||||||
| FaxNumber: | 9037987354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | TX605480 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 150499758 | 05 | AR | MEDICAID |