Provider Demographics
NPI:1912517566
Name:BRUNTRAGER, ANNE SUTHERLAND (MSN, RN, CPNP-PC, CL)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:SUTHERLAND
Last Name:BRUNTRAGER
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC, CL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RUTLAND SQ
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3105
Mailing Address - Country:US
Mailing Address - Phone:617-818-2040
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKLINE PL STE 327
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7238
Practice Address - Country:US
Practice Address - Phone:617-735-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2328766163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2328766OtherREGISTERED NURSE
MARN2328766OtherNURSE PRACTITIONER LICENSE