Healthcare Provider Details

I. General information

NPI: 1821021445
Provider Name (Legal Business Name): DONNA M BRUNELLO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 30TH AVE
KENOSHA WI
53144-1411
US

IV. Provider business mailing address

2305 30TH AVE
KENOSHA WI
53144-1411
US

V. Phone/Fax

Practice location:
  • Phone: 262-597-2020
  • Fax: 262-597-5452
Mailing address:
  • Phone: 262-597-2020
  • Fax: 262-597-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberWI2287
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: