Provider Demographics
NPI:1891776993
Name:BRUNNER, KIRSTIN ELLEN (DO)
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:ELLEN
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 LUNA LN
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4719
Mailing Address - Country:US
Mailing Address - Phone:814-453-4309
Mailing Address - Fax:
Practice Address - Street 1:1020 EAST 1OTH STREET
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16503-0002
Practice Address - Country:US
Practice Address - Phone:814-453-4309
Practice Address - Fax:814-459-1191
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006234L2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1696143Medicaid
F33813Medicare UPIN
PA1696143Medicaid