Healthcare Provider Details

I. General information

NPI: 1063113728
Provider Name (Legal Business Name): EMILY M BRUNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 LAFAYETTE DR
WELDON SPRING MO
63304-7890
US

IV. Provider business mailing address

6005 LAFAYETTE DR
WELDON SPRING MO
63304-7890
US

V. Phone/Fax

Practice location:
  • Phone: 401-584-3939
  • Fax: 216-678-9186
Mailing address:
  • Phone: 401-584-3939
  • Fax: 216-678-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: