Healthcare Provider Details

I. General information

NPI: 1316858244
Provider Name (Legal Business Name): OLIVIA ANNE BRUNELLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

560 HOOKSETT RD
AUBURN NH
03032-3914
US

V. Phone/Fax

Practice location:
  • Phone: 612-365-1000
  • Fax:
Mailing address:
  • Phone: 603-370-1477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: