Provider Demographics
NPI:1710411822
Name:BRUNNER, LATOSCA (AGAC-NP)
Entity type:Individual
Prefix:
First Name:LATOSCA
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:AGAC-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74008272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8272
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:4810 KEMP BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-5222
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ309642363LA2100X
FLAPRN11031715363LA2100X
KY4017745363LA2100X
TXAP132721363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care