Healthcare Provider Details

I. General information

NPI: 1033555115
Provider Name (Legal Business Name): CELINA VERONICA BRUNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-5058
  • Fax:
Mailing address:
  • Phone: 202-476-5058
  • Fax: 202-476-3475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberD0087943
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD047488
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: