MEDICARE: SUNNY BRIGHAM CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1699215517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNNY BRIGHAM CNS

Provider Business Mailing Address
First Line	:	1945 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-6406
Country	:	US
Telephone Number	:	682-334-2411
Fax Number	:	817-330-6414

Provider Business Practice Location Address
First Line	:	1945 6TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-6406
Country	:	US
Telephone Number	:	682-334-2411
Fax Number	:	817-330-6414

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2017
Last Update Date	:	10/24/2020

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