Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 4301113406 | MI |
NPI | 1154764348 |
---|---|
Provider Name | Dr. Brandi Jenks Gunn |
First Address | Decatur, GA 30033-5401 |
Second Address | Traverse City, MI 49684-2345 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2013 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4301113406 | LICENSE (01) | MI |