MEDICARE: KIM ELLEN BRUNETTE M.S.

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	235Z00000X	Speech-Language Pathologist	418	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	736017987116	OTHER	OK	DEPT OF REHAB

General Provider Information

NPI Number	:	1891785747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM ELLEN BRUNETTE M.S.

Provider Business Mailing Address
First Line	:	13720 CALISTOGA DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5113
Country	:	US
Telephone Number	:	405-552-2799
Fax Number	:	405-553-5668

Provider Business Practice Location Address
First Line	:	13720 CALISTOGA DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5113
Country	:	US
Telephone Number	:	405-552-2799
Fax Number	:	405-553-5668

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	02/05/2009

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Directions to “ KIM ELLEN BRUNETTE M.S.” Practice Location

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