Healthcare Provider Details

I. General information

NPI: 1609149970
Provider Name (Legal Business Name): KAITLYN BRANIGAN BRUNNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 E PARK AVE STE 301
STATE COLLEGE PA
16803-6706
US

IV. Provider business mailing address

1850 E PARK AVE STE 301
STATE COLLEGE PA
16803-6706
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-3470
  • Fax: 814-237-2035
Mailing address:
  • Phone: 814-237-3470
  • Fax: 814-237-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS018124
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: