Provider Demographics
NPI:1861296485
Name:BRUNSON, SHELBY RENEE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:RENEE
Last Name:BRUNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:R
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 CLEMENTS LN
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5352
Mailing Address - Country:US
Mailing Address - Phone:509-531-2548
Mailing Address - Fax:
Practice Address - Street 1:1750 CLEMENTS LN
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5352
Practice Address - Country:US
Practice Address - Phone:509-531-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID76133390200000X
WARN60557241390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program