Basic Information
| Provider Information | |||||||||
| NPI: | 1659663805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNDRETT | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNDRETT | ||||||||
| OtherFirstName: | SUSANN | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4520S US HIGHWAY 281 | ||||||||
| Address2: | |||||||||
| City: | BLANCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786065205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308330510 | ||||||||
| FaxNumber: | 8308334307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769046802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256174594 | ||||||||
| FaxNumber: | 3256174593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2011 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 620325 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP120270 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | FO311218 | 01 | TX | CERTIFICATION | OTHER |