Healthcare Provider Details

I. General information

NPI: 1104750561
Provider Name (Legal Business Name): KIMBERLY BRUENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 GREENWICH AVE
GREENWICH CT
06830-5510
US

IV. Provider business mailing address

26 GAIL CT
CARMEL NY
10512-3826
US

V. Phone/Fax

Practice location:
  • Phone: 203-489-3118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17617
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: