Basic Information
| Provider Information | |||||||||
| NPI: | 1417534991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNSON | ||||||||
| FirstName: | MYRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 N I 10 SERVICE RD W | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700066713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 8665002186 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 N I 10 SERVICE RD W | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700066713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 8665002186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2021 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | LA | Y |
No ID Information.