Provider Demographics
NPI:1134794282
Name:BRUNER, MALLORY L
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:L
Last Name:BRUNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 N SYRINGA ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8794
Mailing Address - Country:US
Mailing Address - Phone:208-777-1320
Mailing Address - Fax:208-777-1322
Practice Address - Street 1:849 N SYRINGA ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-8794
Practice Address - Country:US
Practice Address - Phone:208-777-1320
Practice Address - Fax:208-777-1322
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist