Individual
KIERRA LA SHAWN BRUNO-RODGERS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
712 N DEARBORN ST, CHICAGO, IL 60654-3846
(708) 692-0728
Mailing address
420 WINSTON LN, CHICAGO HEIGHTS, IL 60411-1620
(708) 692-0728
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
238000612
IL
246ZS0410X
Surgical Technologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
238000612
REGISTERED SURGICAL ASSISTANT
IL
Enumeration date
10/29/2018
Last updated
10/30/2018
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