Healthcare Provider Details

I. General information

NPI: 1730693656
Provider Name (Legal Business Name): LAXMI BRUNER RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5016 W CYPRESS ST STE 300
TAMPA FL
33607-3809
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 813-644-6235
  • Fax: 813-644-6245
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND6923
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND6923
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: