Healthcare Provider Details

I. General information

NPI: 1093319006
Provider Name (Legal Business Name): TRACEY LYNN BRUNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S HENDERSON BLVD
KILGORE TX
75662-3518
US

IV. Provider business mailing address

1600 S HENDERSON BLVD
KILGORE TX
75662-3518
US

V. Phone/Fax

Practice location:
  • Phone: 903-475-3474
  • Fax: 903-367-0300
Mailing address:
  • Phone: 903-475-3474
  • Fax: 903-367-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1093319006
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1015649
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: