Healthcare Provider Details

I. General information

NPI: 1649409129
Provider Name (Legal Business Name): KATHERINE ANNE BRUNEAU R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

692 COLUMBIA DR
MOLALLA OR
97038-8819
US

IV. Provider business mailing address

692 COLUMBIA DR
MOLALLA OR
97038-8819
US

V. Phone/Fax

Practice location:
  • Phone: 503-759-4997
  • Fax:
Mailing address:
  • Phone: 503-759-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200141362RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: