Healthcare Provider Details

I. General information

NPI: 1952300147
Provider Name (Legal Business Name): NICOLE ANN BRUNS MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 SECOR RD
TOLEDO OH
43623-4299
US

IV. Provider business mailing address

1012 LONES DR
PERRYSBURG OH
43551-2332
US

V. Phone/Fax

Practice location:
  • Phone: 419-469-6884
  • Fax: 888-363-3695
Mailing address:
  • Phone: 419-356-7504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4616
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: