Provider Demographics
NPI:1407639933
Name:WUNDER, BREAWNNA BLAESING (RN)
Entity type:Individual
Prefix:MS
First Name:BREAWNNA
Middle Name:BLAESING
Last Name:WUNDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 STATE ROAD 382
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-8708
Mailing Address - Country:US
Mailing Address - Phone:612-760-1518
Mailing Address - Fax:
Practice Address - Street 1:1331 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6282
Practice Address - Country:US
Practice Address - Phone:575-758-3601
Practice Address - Fax:505-579-4669
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-79465163WP0808X
NM79552363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health